Association Between Eyelid Laxity and Obstructive Sleep Apnea

Obstructive Sleep Apnea Associated With Increased Failure Rate of Ptosis Repair

PURPOSE

This study investigates how Obstructive sleep apnea (OSA) affects the outcomes of ptosis repair. We hypothesized that patients with OSA have an increased rate of reoperation after ptosis repair.

METHODS

This retrospective cohort study included patients age >18 from the Mayo Clinic who underwent ptosis repair by levator advancement or Müller muscle-conjunctiva resection between 2018 and 2021. Outcomes were measured at 1 to 3 months of follow-up with surgical failure defined as asymmetry or unsatisfactory eyelid height requiring revision surgery within 1 year.

RESULTS

A total of 577 patients met the inclusion criteria. There was a statistically significant difference in surgical failure between patients with OSA and those without (20.5% vs. 13.1%, p = 0.02). Patients with OSA showed a statistically significant difference in risk of revision by a factor of 1.70 (95% CI: 1.06-2.07). Revisions were attributed to unsatisfactory eyelid height in 72.6% of patients and eyelid asymmetry in 21.1%. All patients who had revision surgery had satisfactory outcomes. On logistic regression analysis, when adjusting for age and sex, OSA was significantly associated with ptosis revision ( p = 0.007).

CONCLUSIONS

OSA increases risk of surgical failure and need for revision surgery in patients undergoing blepharoptosis repair but is not a sole risk factor.

Comparison of ocular surface assessment outcomes between healthy controls and patients with obstructive sleep apnea-hypopnea syndrome: a meta-analysis of the literature

Objective: This meta-analysis aims to determine whether ocular surface alterations are associated with disease severity in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Methods: The protocol for this systematic review and meta-analysis was registered in PROSPERO. We conducted the search in six electronic databases (China National Knowledge Infrastructure, EMBASE, Cochrane Library, Web of Science, Wanfang, and PubMed) from since the construction of the databases to 30 December 2022. The standard mean difference (SMD) and correlation coefficients are reported as measures of the effect size in the presence of retrieved data. In addition, the random effects model or fixed effects model was used in a combined analysis. Stata 11.0 and R 3.6.1 were used for statistical analyses of the data. Results: A total of 15 studies satisfied the inclusion criteria for this study. The prevalence of floppy eyelid syndrome (FES) and dry eye syndrome in patients with obstructive sleep apnea-hypopnea syndrome was 40 and 48%, respectively. In addition, the Schirmer 1 value and tear break-up time (TBUT) were remarkably reduced in patients with OSAHS when compared to that of the controls. The ocular surface disease index (OSDI) scores, Oxford corneal staining scores, and the rates of loss in the meibomian glands were elevated in patients with obstructive sleep apnea-hypopnea syndrome when compared to that of the controls, especially those with severe disease. Moreover, the Schirmer 1 value and tear break-up time exhibited a negative correlation with the apnea-hypopnea index (AHI), and the OSDI showed a positive association with the apnea-hypopnea index. Conclusion: Patients with OSAHS had a greater prevalence of FES than the healthy controls. They also showed lower Schirmer 1 value and tear break-up time but had a higher OSDI, Oxford corneal staining scores, and rates of loss in the meibomian glands than the healthy controls. Clinical Trial Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=392527).

Prevalence of Obstructive Sleep Apnea With Floppy Eyelid Syndrome: A Systematic Review and Meta-analysis

PURPOSE

This study investigated the prevalence of obstructive sleep apnea (OSA) in floppy eyelid syndrome (FES) patients and evaluated the severity of OSA with FES prevalence.

METHODS

Cochrane CENTRAL, Medline, Science Direct, Google Scholar, and PubMed databases were searched for studies on FES patients and its association with OSA syndrome, of any design, published from January 1, 1997, to January 1, 2022. A random-effects model that weighted the studies was used when there was heterogeneity between studies ( p < 0.10) and if I 2 values were more than 50%. All p values were 2-tailed and considered statistically significant if <0.05.

RESULTS

A total of 12 studies comprising 511 patients were included in this meta-analysis. Of these, 368 were male (77.6%) and the average age was 55.10 years. The overall prevalence of OSA in FES patients was 57.1% (95% CI: 46.5-74.8%), M:F ratio was 48:1 (98% male), and 69.1% of patients received their OSA diagnosis at the time of the study. Of those with FES, tear film abnormalities were the most common ocular comorbidity (78.9%) followed by keratoconus (20.6%), glaucoma (9.8%), and lower eyelid ectropion (4.6%). Obesity was the most common systemic morbidity (43.7%) followed by hypertension (34.0%) and diabetes mellitus (17.9%).

CONCLUSION

This meta-analysis demonstrates OSA is a common comorbidity in the FES population. Ophthalmologists are often the first to evaluate patients with FES, and considering this coincidence, routine screens for sleep apnea symptoms in at-risk FES patients should be undertaken. Large case-control studies are required to better elucidate the exact prevalence of OSA and other morbidities in patients with FES, and to better understand the etiology of FES.

Lax eyelid condition (LEC) and floppy eyelid syndrome (FES) prevalence in obstructive sleep apnea syndrome (OSA) patients: a systematic review and meta-analysis

Purpose

Lax eyelid condition (LEC) and floppy eyelid syndrome (FES) represent two distinct conditions which have been associated with several ocular and systemic comorbidities. The main aim of this systematic review and meta-analysis is to explore the available literature to estimate the prevalence rate of LEC and FES in obstructive sleep apnea (OSA).

Methods

The protocol of this systematic review and meta-analysis has been registered in PROSPERO. Four electronic databases (PubMed/MEDLINE, Google Scholar, Cochrane Library, Web of Science) were searched from inception to December 24, 2021. A random intercept logistic regression model was carried out for the analysis of overall proportions. Odds ratio and mean difference were reported as measures of the effect size in the presence of binary and continuous outcomes, respectively. The estimated numbers of LEC/FES patients in OSA were calculated by multiplying the prevalence rate determined by our random-effects model and the corresponding Benjafield et al.’s population prospect.

Results

We included 11 studies comprising 1225 OSA patients of whom 431 and 153 affected by LEC and FES, respectively. Our model estimated a pooled prevalence rate for LEC and FES in OSA patients of 40.2% (95%CI: 28.6–53.1%) and of 22.4% (95%CI: 13.8–34.2%), respectively. The number of LEC/FES affected individuals among OSA patients is expected to peak up to 376 and to 210 million, respectively. OSA patients appeared to have a 3.4 (95%CI: 2.2–5.2) and a 3.0 (95%CI: 1.7–5.5) increased risk of developing LEC and FES than the healthy counterpart.

Conclusion

Prevalence of LEC and FES is higher in OSA-affected patients compared to controls. More studies are warranted to investigate the mechanisms leading to the development of LEC and/or FES in OSA patients, as well as the feasibility of the adoption of these clinical findings as screening tools for OSA.

The Associations of Obstructive Sleep Apnea and Eye Disorders: Potential Insights into Pathogenesis and Treatment

Purpose of Review

Obstructive sleep apnea (OSA) patients are at significantly increased risks for cardiovascular and cerebrovascular morbidities. Recently, there has been heightened interest in the association of OSA with numerous ocular diseases and possible improvement of these conditions with the initiation of OSA treatment. We reviewed the current evidence with an emphasis on the overlapping pathogeneses of both diseases.

Recent Findings

Currently available literature points to a substantial association of OSA with ocular diseases, ranging from those involving the eyelid to optic neuropathies and retinal vascular diseases. Since the retina is one of the highest oxygen-consuming tissues in the body, the intermittent hypoxia and hypercapnia ensuing in OSA can have deleterious effects on ocular function and health. Tissue hypoxia, autonomic dysfunction, microvascular dysfunction, and inflammation all play important roles in the pathogenesis of both OSA and ocular diseases. Whether OSA treatment is capable of reversing the course of associated ocular diseases remains to be determined. It is anticipated that future therapeutic approaches will target the common underlying pathophysiologic mechanisms and promote favorable effects on the treatment of known associated ocular diseases.

Summary

Emerging evidence supports the association of ocular diseases with untreated OSA. Future studies focusing on whether therapeutic approaches targeting the common pathophysiologic mechanisms will be beneficial for the course of both diseases are warranted.

Evaluation of Periorbital Tissues in Obstructive Sleep Apnea Syndrome

Objectives:

To evaluate periorbital tissue alterations including eyelid laxity and eyelash ptosis in patients with obstructive sleep apnea syndrome (OSAS).

Materials and Methods:

Based on polysomnography, 96 eyes of 48 patients with moderate/severe OSAS (Group 1) and 44 eyes of 22 patients with simple snoring (Group 2) were enrolled. Comprehensive eye examination along with eyelid laxity measurements including vertical and anterior distraction, presence of dermatochalasis, interpalpebral distance, and levator function were assessed. The presence and severity of eyelash ptosis were also noted.

Results:

The mean ages of Group 1 and Group 2 were 49.9±11.4 (range: 26-67) and 50.6±8.9 (range: 27-69) years, respectively (p=0.557). The mean vertical and anterior distraction distances in Group 1 (13.3±4.1 [range, 6-27] mm and 7.4±2.1 [range, 3-13.5] mm, respectively) were significantly higher than in Group 2 (p<0.05). Dermatochalasis and eyelash ptosis were found to be significantly more frequent in Group 1 (52.1% and 81.3%, respectively). The severity of eyelash ptosis was also higher in OSAS (p<0.05). No significant difference in interpalpebral distance or levator muscle function was detected.

Conclusion:

In patients with severe OSAS, eyelid laxity was more prominent and eyelash ptosis was more frequent and severe.

Assessment of Obstructive Sleep Apnoea and Sleeping Laterality by Evaluating Upper Eyelid Distraction: A Prospective, Comparative Polysomnographic Study

Objective Our goal was to evaluate upper eyelid laxity by digital distraction, with the aim to determine sleeping laterality and the likelihood of obstructive sleep apnoea (OSA), and correlate these findings with polysomnography (PSG). Design We conducted a prospective, single-centre multidisciplinary study in a large sleep and respiratory department and an ophthalmology department within a tertiary referral university teaching hospital. Methods Patients with known OSA were evaluated using techniques based on the Lateralising Eyelid Sleep Compression (LESC) study. Upper eyelid laxity was assessed by two masked investigators, and the eyelid side with greater laxity was regarded as indicative of that patient's sleeping laterality: 'investigator-detected sleeping laterality' (ID SL). Each patient was then asked about the laterality of his or her accustomed sleeping position: 'patient-reported sleeping laterality' (PR SL). PSG was conducted according to the standard protocol of the Department of Sleep and Respiratory Medicine (DSRM). 'Polysomnography-detected sleeping laterality' (PSG SL) permitted the extraction of sleep positional data by two masked sleep scientists. Results The reliability of the LESC technique for diagnosing ID SL was demonstrated to be statistically significant (p<0.01). Upper eyelid laxity was significantly greater on the patients' sleeping side (t=6.340, df=45, p<0.01, two-tailed). There was a significant correlation between PR SL and ID SL (r_s =0.33). However, PSG SL did not correlate with sleeping laterality compared with both ID SL and PR SL. Conclusion This study confirms that there is a statistically significant correlation of sleeping laterality with increasing upper eyelid laxity in OSA. Counterintuitively, PSG SL correlated poorly with ID SL and PR SL. This may likely be explained by the technical limitations implicit in current PSG techniques.

Prospective Evaluation of Floppy Eyelid Syndrome at Baseline and after CPAP Therapy

PURPOSE/AIM

Floppy eyelid syndrome (FES) is an ocular manifestation of obstructive sleep apnea (OSA), but no studies have analyzed whether it can be improved by nocturnal continuous positive airway pressure (CPAP) therapy. The aim of this study was to analyze the effect of CPAP on FES by comparing objective measurements before and after 6 months of CPAP therapy.

MATERIALS AND METHODS

We conducted a prospective study of 47 patients (74.5% males) with newly diagnosed OSA at a secondary care Portuguese hospital who underwent objective diagnostic testing for FES (upper eyelid eversion for >6 seconds and tarsal conjunctival exposure and upper eyelid laxity ≥1.5 mm). Patients with hyperelastic eyelid or FES were re-evaluated by the same ophthalmologist (blinded to the patients' condition) after 6 months of CPAP therapy.

RESULTS

Mean apnea hypopnea index (AHI), analyzed as number of events per hour, was 28.7 ± 18.6 overall and 42.8 ± 20.0 in the supine position. Thirty-four percent of patients had FES. Mean AHI in the supine position was significantly higher in patients with FES (p = .041) and was an independent predictor of FES (p = .034; OR = 0.48). Severe OSA was significantly associated with FES (p = .023). FES resolved in 53.8% of patients after CPAP therapy. Patients with non-reversible FES had more severe OSA and worse airway access according to the Mallampati classification (from class I: visualization of soft palate and entire uvula, to class IV: soft palate not visible).

CONCLUSIONS

A higher AHI in the supine position may be predictive of FES. CPAP therapy might reverse FES and patients with non-reversible FES appear to have more severe OSA and a worse airway access.

Obstructive Sleep Apnea and Keratoconus: A Systematic Review and Meta-analysis

BACKGROUND

Despite the increasing number of studies focused on the association between obstructive sleep apnea (OSA) and keratoconus (KC), to date, no comprehensive meta-analysis or systematic review was published.

OBJECTIVE

The objective of this study was to evaluate the association between OSA and KC.

DATA SOURCES

Sources of data were PubMed, Scopus, and Web of Science databases.

STUDY ELIGIBILITY CRITERIA

The criteria for study eligibility were case-control studies and cohort studies reporting data on the association of OSA with KC with risk ratio, odds ratio, or hazard ratio with 95% confidence intervals or sufficient raw data for calculation.

STUDY APPRAISAL AND SYNTHESIS METHODS

Meta-analysis was conducted with a random-effects model using odds ratio with 95% confidence interval as the effect size. Heterogeneity was evaluated using the Q and I tests. Sensitivity analysis and assessment of publication bias were performed.

RESULTS

Five studies (four case-control studies and one cohort study) published between 2012 and 2016 and involving 33,844 subjects (16,922 patients with KC, 16,922 controls) were included in this meta-analysis. A significant association between OSA and KC has been shown (pooled odds ratio, 1.841; 95% confidence interval, 1.163 to 2.914; P = .009). A significant heterogeneity was observed (Q = 15.8, I = 74.6%). There was no evidence of significant publication bias (P = .07). The sensitivity analyses indicated the stability of results.

LIMITATIONS

Heterogeneity across the studies was observed. Data from four hospital-based case-control studies and one large population-based cohort study were combined. Most of the included studies ascertained OSA by the Berlin Questionnaire, which is a screening tool.

CONCLUSIONS

This meta-analysis provides significant evidence that OSA is associated with KC. Therefore, a proper screening for OSA is warned for KC patients for the prevention of various cardiovascular comorbidities. Further prospective studies are warranted to explore more in-depth the casual relationship between the two conditions.

Floppy eyelid syndrome: A comprehensive review

Floppy eyelid syndrome (FES) is defined as eyelid hyperlaxity with reactive palpebral conjunctivitis. It is a common condition that can be associated with significant ocular irritation. FES presents with easily everted eyelids and chronic papillary conjunctivitis in the upper eyelids. It is frequently associated with ocular and systemic diseases, notably keratoconus and obstructive sleep apnea, respectively. This comprehensive review describes the epidemiology, pathological changes, proposed pathogenesis, clinical manifestations, and a variety of treatment options for this condition. Conservative treatment of FES includes aggressive lubrication, nighttime eye shield, and avoiding sleeping on the affected eye. Patients with FES and obstructive sleep apnea may have an improvement in their ocular signs and symptoms after long-term therapy with continuous positive airway pressure. In refractory cases, a corrective surgery that addresses the eyelid laxity can result in significant improvement. All patients with ocular irritation should be evaluated for the presence of FES.

Assessment of physiological upper eyelid laxity

PURPOSE

To evaluate overall upper eyelid laxity according to age and sleep position.

METHODS

This single-center prospective study was conducted on healthy subjects between 20 and 89 years of age and was approved by the institutional review board and the ethics committee. Data collected were age, sex, weight and height, ophthalmological history, general history (diabetes, hypertension, smoking) and preferred sleep position (lateral, ventral, dorsal decubitus or no preference). Overall upper eyelid laxity was measured using the McNab technique.

RESULTS

In total, 280 patients were included in the study - 40 per 10-year age bracket. Mean overall right eyelid laxity was measured at 5.35mm (5.38mm on the left) between 20 and 29 years old and 8.28mm (8.43mm on the left) between 80 and 89 years old. 161 patients slept in a lateral decubitus position. Median overall upper eyelid laxity for the sleep side was 8mm vs. 7mm for the non-sleep side.

CONCLUSION

Overall upper eyelid laxity increased significantly with age (P<0.001) and compared to the contralateral side (P<0.001). Overall upper eyelid hyperlaxity can be defined as a measurement (by the McNab technique) greater than: 7mm between 20 and 29 years, 8mm between 30 and 39 years, 9mm between 40 and 69 years and 10mm between 70 and 89 years. This study provides new data on normal eyelid laxity in the general population according to age and sleep position.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is increasing in prevalence due to rising obesity. While OSA is a disorder primarily of the upper airway during sleep, its pathophysiological impact on other body systems is increasingly recognised. There has been interest in the prevalence of OSA in different ophthalmic conditions and possible causation has been postulated. As OSA is common, it can be expected that people with co-existent OSA will be found in any ophthalmic disease population studied. To determine with confidence the significance of finding patients with OSA in a particular cohort requires a well matched control group, ideally matched for age, obesity, gender and co-morbidities. Only if one can say with certainty that the prevalence of OSA is higher in a group with a particular co-existent ophthalmic disease can we begin to speculate about possible mechanisms for the overlap in these conditions. Possible mechanisms for how OSA might affect the eye are discussed in this review. The current literature is reviewed with respect to diabetic retinopathy, glaucoma, floppy eyelid syndrome, non-arteritic ischaemic optic neuropathy, keratoconus and AMD. Associations with OSA have been found, but robust prospective studies using multi-channel sleep studies to diagnose OSA are lacking. Gaps remain in the evidence and in our knowledge. It is hoped that this review will highlight the need for ophthalmologists to consider OSA in their patients. It also makes recommendations for future research, especially to consider whether therapies for OSA can also be effective for ophthalmic disorders.