The prevalence of glaucoma in patients with sleep apnea syndrome: same as in the general population

The Sleep Health of Individuals with Visual Impairments: A Scoping Review

PURPOSE

Amidst the global aging population and an increasing prevalence of visual impairment across all age groups, this study aims to investigate the current state of research on sleep health in visually impaired populations.

METHODS

A scoping review was conducted to synthesize the existing literature on sleep health and visual impairment. We employed conceptual mapping to identify key research topics, analyzing data from four databases: PubMed (n = 290), CINAHL (n = 81), Scopus (n = 117), and PsycInfo (n = 96). A total of 83 peer-reviewed articles, published from 1977 to August 2023, were included in the review.

RESULTS

Our analysis identified 11 distinct eye health conditions including blindness, glaucoma, diabetic retinopathy, low vision, cataract, retinitis pigmentosa, macular degeneration, optic neuropathy, visual field defects, ocular hypertension, and retinal vein occlusion. Additionally, 8 major sleep problems were recognized: abnormal sleep duration, daytime sleepiness, insomnia, Non-24-Hour Sleep Wake Disorder, sleep apnea, sleep disorders, sleep disturbances, and sleep disordered breathing. The dominant research themes were (1) poor sleep quality in individuals with visual impairments and ophthalmic diseases, (2) high prevalence of sleep issues in patients with ophthalmic diseases, (3) sleep apnea in patients with ophthalmic conditions, and (4) circadian rhythm disruptions in blind individuals.

CONCLUSION

This review highlights research gaps that, when addressed, could greatly enhance our comprehension of the interplay between visual impairment and sleep health. Bridging these gaps promises to lead to more holistic care strategies, potentially improving vision functioning and rehabilitation outcomes for individuals with visual impairments.

Familial normal tension glaucoma genetics

Glaucoma is defined by characteristic optic nerve damage and corresponding visual field defects and is the leading cause of irreversible blindness in the world. Elevated intraocular pressure (IOP) is a strong risk factor for developing glaucoma. However, glaucoma can occur at any IOP. Normal tension glaucoma (NTG) arises with IOPs that are within what has been defined as a normal range, i.e., 21 mm Hg or less, which may present challenges in its diagnosis and management. Identifying inheritance patterns and genetic mutations in families with NTG has helped elucidate mechanisms of NTG, however the pathophysiology is complex and not fully understood. Approximately 2% of NTG cases are caused primarily by mutations in single genes, optineurin (OPTN), TANK binding kinase 1 (TKB1), or myocilin (MYOC). Herein, we review pedigree studies of NTG and autosomal dominant NTG caused by OPTN, TBK1, and MYOC mutations. We review identified mutations and resulting clinical features of OPTN-associated and TBK1-associated NTG, including long-term follow up of these patients with NTG. In addition, we report a new four-generation pedigree of NTG caused by a Glu50Lys OPTN mutation, including six family members with a mean follow up of 17 years. Common features of OPTN -associated NTG due to Glu50Lys mutation included early onset of disease with an IOP <21 mm Hg, marked optic disc cupping, and progressive visual field loss which appeared to stabilize once an IOP of less than 10 mm Hg was achieved. Lastly, we review risk factor genes which have been identified to contribute to the complex inheritance of NTG.

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).

Long-term effects of obstructive sleep apnea and its treatment on open-angle glaucoma: a big-data cohort study

STUDY OBJECTIVES

The relationship between open-angle glaucoma (OAG) and obstructive sleep apnea (OSA) is unclear. The long-term risk for OAG after OSA diagnosis has not been investigated. Therefore, we assessed the risk for OAG among patients with OSA over a 12-year follow-up period using nationwide, population-based data.

METHODS

The OSA group was randomly selected from among 3.5 million individuals registered with the National Health Insurance Service. The non-OSA group was obtained through propensity score matching considering several variables. The primary endpoint was glaucoma diagnosis.

RESULTS

The OSA and non-OSA groups both included 6,369 individuals. The overall hazard ratio for OAG in the OSA group was 1.42 (95% confidence interval [CI]: 1.19-1.69). In subgroup analysis, the hazard ratio for OAG was 1.94 (95% CI: 1.57-2.41) for those aged > 60 years, 1.50 (95% CI: 1.20-1.89) for those with diabetes mellitus, 1.53 (95% CI: 1.26-1.86) for those with hypertension, and 0.71 (95% CI: 0.52-0.96) for those with a history of OSA surgery.

CONCLUSIONS

Over the 12-year follow-up, the risk for OAG increased after OSA diagnosis. Further research will be necessary to determine if treating OSA can mitigate this association.

CITATION

Lee T-E, Kim JS, Yeom SW, Lee MG, Lee JH, Lee H-J. Long-term effects of obstructive sleep apnea and its treatment on open-angle glaucoma: a big-data cohort study. J Clin Sleep Med. 2023;19(2):339-346.

Obsructive sleep apnea syndrome: is it a risk factor for ocular surface disease and ocular comorbidities?

PURPOSE

To investigate the accompanying ocular findings in patients with obstructive sleep apnea syndrome (OSAS) and evaluate the susceptibility to ophthalmological diseases.

MATERIALS AND METHODS

In this cross-sectional study, qualifying study subjects were patients who had been diagnosed with severe OSAS (apnea/hypopnea index (AHI > 30/h), n = 31), and control subjects (n = 30) who had an AHI index of < 5 (as normal). General ophthalmological examination, eyelid laxity measurements, corneal topography, visual field, retinal nerve fiber layer parameters, dry eye tests were performed on the patients.

RESULTS

It was observed that the two groups had similar characteristics in terms of gender, age, presence of hypertension, diabetes, and body mass index. According to eyelid laxity measurements, the incidence of loose eyelids was higher in the OSAS patient group. Choroidal thickness was thinner in the study group than in the control group. Schirmer test and tear break-up time were significantly lower in the study group than in the control group. The percentage of meibomian gland loss in meibography and the ocular surface disease index score for symptoms was significantly higher in the study group than in the control group.

CONCLUSION

In this study, we found significant changes in ocular surface parameters, eyelid laxity, choroidal thickness, and visual field indices in OSAS patients. Dry eye syndrome might be related eyelid laxity and inflammation in OSAS patients. Early diagnosis and follow-up of ocular diseases in OSAS, which affect the quality of life and visual prognosis in advanced ages, are important.

Association Between Risk of Obstructive Sleep Apnea and Glaucoma: The Singapore Epidemiology of Eye Diseases Study

PRCIS

In this population-based, cross-sectional study of Indian and Malay adults in Singapore aged 40 years or above, intermediate or high risk of obstructive sleep apnea (OSA) was associated with 50% higher odds of having glaucoma.

BACKGROUND/AIMS

The relationship between OSA and glaucoma is unclear. We assessed the association between the risk of OSA and glaucoma in an Asian population.

MATERIALS AND METHODS

In this population-based, cross-sectional study, we included Indian and Malay adults aged 40 years or above recruited between 2011 and 2015. Glaucoma was assessed by trained ophthalmologists and classified into primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG). OSA risk was assessed with the Snoring, Tiredness, Observed apnea, High blood pressure, Body mass index, Age, Neck circumference, and male Gender (STOP-Bang) questionnaire and categorized as low risk (<3) or intermediate/higher risk (≥3). We used multivariable logistic regression models to evaluate the relationship between risk of OSA and glaucoma adjusted for key variables, and further stratified for subtype and ethnicity.

RESULTS

Of the 3126 participants (mean age: 63.1±9.6 y; 52.5% female), 134 (4.3%) had glaucoma, comprising 86 (2.8%) POAG, 22 (0.7%) PACG and 26 (0.8%) secondary glaucomas, and 1182 (37.8%) had an intermediate/higher risk of OSA. Compared with individuals with a low risk of OSA, individuals with intermediate/higher risk had 50% greater odds of having glaucoma (odds ratio: 1.55, 95% confidence interval: 1.03-2.33; P =0.035). We observed a nonsignificant increase in likelihood of having POAG in those with intermediate/higher risk of OSA compared with those with low risk. The OSA-glaucoma relationship was modified by ethnicity, with Malays with intermediate/higher risk of OSA having a 2-fold risk of having any glaucoma (odds ratio: 2.01, 95% confidence interval: 1.12-3.59 P =0.019); while the same elevated risk was not observed for Indians.

CONCLUSIONS

Intermediate or high risk of OSA is associated with 50% higher odds of having glaucoma in our Singaporean population, with a 2-fold higher risk of glaucoma observed in Malays (but not Indians); however a conformational sleep study is needed.

The effect of positive airway pressure therapy on intraocular pressure and retina in severe obstructive apnea syndrome

To identify and compare changes in intraocular pressure (IOP), macular, and peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography (OCT) measurements before and after 3 months of positive airway pressure (PAP) therapy in patients with severe obstructive sleep apnea syndrome (OSAS). Twenty-five patients diagnosed with severe OSAS in the neurology sleep outpatient clinic were included in the study. Ophthalmologic examinations were performed at the time of diagnosis and after 3 months of PAP therapy. Statistical analysis of comparisons of pre-treatment and post-treatment measurements of IOP and OCT was performed. Before the PAP therapy, the correlations between central corneal thickness (CCT), body mass index (BMI), OCT, IOP, and sleep parameters were statistically analyzed. Compared to the pre-treatment measurements at the time of diagnosis, post-treatment measurements showed insignificant decrease in IOP, significant increase in mean macular thickness and significant thinning in superior nasal RNFL. There was no correlation found between pre-treatment measurements including IOP, OCT, CCT, BMI, and sleep parameters. The effect of intermittent hypoxia and hypercapnia on the IOP and macula may be reversible in severe OSAS patients receiving 3 months of PAP therapy, but the reversibility of the neurodegenerative effects of OSAS on RNFL with this treatment seems controversial. OCT can be considered to be a promising technique for monitoring disease progression under PAP therapy in patients with severe OSAS.

Sleep and eye disease: A review

There is a growing body of literature on the effects of sleep disorders, in particular obstructive sleep apnoea (OSA), on ocular health, with consistent evidence of an increased risk of floppy eyelid syndrome, non-arteritic anterior ischaemic optic neuropathy, diabetic macular oedema, and other retinal vasculature changes in individuals with OSA. However, reports on OSA's associations with glaucoma, papilloedema, diabetic retinopathy, central serous chorioretinopathy, and keratoconus have been conflicting, while links between OSA and age-related macular degeneration have only been described fairly recently. Despite numerous suggestions that OSA treatment may reduce risk of these eye diseases, well-designed studies to support these claims are lacking. In particular, the ocular hypertensive effects of continuous positive airway pressure (CPAP) therapy for OSA requires further investigation into its potential impact on glaucoma risk and management. Reports of ocular surface complications secondary to leaking CPAP masks highlights the importance of ensuring good mask fit. Poor sleep habits have also been linked with increased myopia risk; however, the evidence on this association remains weak.

Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms

Eye diseases are an important group of increasingly prevalent disorders that contribute very significantly to disability and represent a considerable health burden. Some data suggest that several of these diseases may be associated with sleep-disordered breathing, mainly obstructive sleep apnea (OSA), due to intermediate mechanisms, such as intermittent hypoxia or sleep fragmentation. The aims of this systematic review were to identify and critically evaluate the current evidence supporting the existence of a possible relationship between OSA and the more relevant eye diseases as well as to evaluate the potential pathogenic mechanisms. There is a body of largely low-level evidence for the association of OSA with glaucoma, nonarteritic ischemic optic neuropathy, central serous chorioretinopathy, and diabetic retinopathy. Meta-analysis of available case-control studies shows that OSA increases the risk of glaucoma (pooled odds ratio: 1.50; 95% confidence interval: 1.25 to 1.80; P < .001), nonarteritic ischemic optic neuropathy (3.62; 1.94 to 6.76; P < .001), and diabetic retinopathy (1.57; 1.09 to 2.27; P = .02). Moreover, several pathogenic pathways have been identified, mainly related to hypoxic damage, mechanical stress, systemic inflammation, oxidative stress, sympathetic tone, and endothelial dysfunction. In contrast, information about the effect of apnea-hypopnea suppression on the development and progression of eye damage is either nonexistent or of a very low level of evidence. In conclusion, OSA has emerged as an additional potential risk factor for many eye diseases, although their link is weak and contradictory, so further examination is required.

CITATION

García-Sánchez A, Villalaín I, Asencio M, García J, García-Rio F. Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms. J Clin Sleep Med. 2022;18(1):265-278.

The Risk of Obstructive Sleep Apnea in Open-Angle Glaucoma Patients

Background This study aimed to assess the risk of obstructive sleep apnea (OSA) in glaucoma patients using the STOP-BANG questionnaire at the King Abdulaziz University Hospital (KAUH), a tertiary care center in Saudi Arabia. Methodology This study used a cross-sectional telephone survey. Patients older than 18 years diagnosed with open-angle glaucoma, without a diagnosis of respiratory disease or steroid use, completed the STOP-BANG questionnaire, a validated tool to determine the risk for developing OSA. Patients with a score of 3 or more were considered at intermediate risk of OSA, and those with a score of 5 or more of the maximum 8 points were considered to have a high risk for moderate/severe OSA. Social demographic information and medical histories were collected from all patients using the medical record system of the KAUH. Results A total of 77 patients with glaucoma were included in the study. The mean STOP-BANG score was 3.40 ± 1.5; 27.3% of the patients had low risk of OSA, 36.4% had intermediate risk, and 36.4% had high risk. An evaluation of the OSA symptoms found snoring, tiredness, and observed apnea in 29.9%, 36.4%, and 14.3% of patients, respectively. The association between body mass index and STOP-BANG score was significant. Conclusions Our analysis and assessment of the association between glaucoma and OSA found no evidence that glaucoma patients are more likely to have OSA or develop more severe OSA than others. Therefore, we do not recommend systematic screening of glaucoma patients for OSA.

Obstructive sleep apnea as a risk factor for primary open angle glaucoma and ocular hypertension in a monocentric pilot study

Background

Both glaucoma and obstructive sleep apnea (OSA) are widespread diseases. OSA may presumably partly cause or worsen glaucoma, although the etiopathogenesis is unclear. Here we analyze for the first time the possible association between different glaucoma phenotypes and OSA.

Methods

110 patients (47 females, 63 males; median age 64.3 years, median BMI 26.62 kg/m²) with suspected glaucoma and without any prior diagnosis of OSA were prospectively studied by one-night home sleep apnea testing (HSAT), 101 of the patients were analyzed. HSAT parameters, like apnea hypopnea index (AHI) and oxygen desaturation index as well as opthalmological parameters like intraocular pressure (IOP) and mean defect depth (MD) were collected. Moreover, HSAT results were compared across four phenotypic groups: primary open angle glaucoma (POAG), low-tension-glaucoma (LTG), ocular hypertension (OH), and controls.

Results

There was no strong correlation between IOP or MD and AHI. BMI, age and gender did not differ between groups. Significant differences between POAG and LTG were found for all HSAT parameters. The AHI showed the most prominent group difference (Wilcoxon-Kruskal-Wallis rank sum test was highly significant with chi² = 22, df = 3 p < 0.0001) with severely lower event rates in the LTG (9.45/h) compared to POAG (22.7/h) and controls (21.9/h; p < 0.0001 and 0.02, respectively). Highly significant differences were found between the four groups regarding AHI (Chi² = 22, df = 3, p < 0.0001) with significantly lower events per hour in the LTG compared to POAG (Hodges-Lehmann = − 13.8, 95% CI (− 18.6 – − 8.8; p < 0.0001) and to controls (Hodges-Lehmann = 12.1, 95% CI -19.9 – − 2.4; p < 0.02). Severe and moderate OSA was more prevalent in POAG (69.8%) and OH (33.3%) than in LTG (9%). The effect of the glaucoma phenotype on the AHI was more prominent in females (p = 0.0006) than in males (p = 0.011).

Conclusion

Although physical endpoints, such as MD and IOP, do not correlate with AHI, there was a strong correlation between the POAG and OH clinical glaucoma phenotypes and the AHI. Further studies should investigate the necessity to test routine screening for OSA by HSAT in patients with diagnosed POAG and OH. Besides, some characteristics of LTG differed widely from other glaucoma types and controls. LTG patients had a significantly lower rate of OSA compared to other glaucoma types and even controls. This might be due to a different pathogenesis of LTG.

Trial registration

Retrospectively registered at DRKS (nr. S00021201) on April 9th 2020.

Links between obstructive sleep apnea and glaucoma neurodegeneration

In the last few years, the possible link between obstructive sleep apnea (OSAS) and glaucoma, has attracted the interest of many scientists, especially in those forms of primary open angle glaucoma (POAG) and normal tension glaucoma (NTG), in which a progression of the disease occurs, even though intraocular pressure (IOP) is in the range of normality. The increased prevalence of POAG or NTG in patients affected by OSAS, and vice versa, has stimulated interest in the pathogenetic mechanisms that could trigger these two diseases. Hypoxia generated by apnea/hypopnea cycles has been identified as the main cause of many changes in the vascular and neurological systems, which alter the functioning not only of the optic nerve, but also of the whole organism. However, many other factors could be involved, like mechanical factors, obesity, hormonal imbalance and other sleep disorders. Furthermore, the demonstration of typical glaucomatous or glaucoma-like changes in the anatomy or function of the optic nerve and retinal nerve fiber layer by sensitive specific and diagnostic methods, such as perimetry, optical coherence tomography (OCT), optical coherence tomography angiography (OCTA) and electrophysiological exams keeps interest high for this field of study. For this reason, further investigations, hopefully a source of stronger scientific evidences, are needed.

Prevalence of Glaucoma in Patients with Obstructive Sleep Apnea

To determine the prevalence of glaucoma in obstructive sleep apnea (OSA) patients and compare it with that of patients without OSA. Patients investigated for OSA using polysomnography at the sleep center of King Abdulaziz University Hospital were invited to participate in this cross-sectional case series study. American Academy of Sleep Medicine guidelines were used to diagnose OSA. Recruitment of patients with and without OSA was conducted from December 2013 to September 2015. Exclusion criteria included topical and systemic steroid use and presence of other ocular diseases. Two criteria, cup/disc ratio and visual field defects, were necessary for a glaucoma diagnosis. Among 84 adults enrolled, 44 (52%) had a confirmed diagnosis of OSA. Glaucoma prevalence was higher among individuals with OSA (16%) than among non-OSA individuals (8%), a difference that was not statistically significant. A consistent trend, which was not statistically significant after adjusting for cofounders, toward more glaucomatous changes was observed in OSA subjects. Although a trend toward higher glaucoma prevalence was observed in OSA patients, the difference was not statistically significant. As many variables contribute to the development of the two conditions, larger cohorts are needed to evaluate associations between glaucoma and OSA.

Neuro-Ophthalmological Manifestations of Obstructive Sleep Apnea: Current Perspectives

Obstructive sleep apnea (OSA) is a disease of obstructed airways during sleep that significantly impacts the quality of life and increases the risk of various systemic diseases. OSA has been studied as a risk factor for a number of neuro-ophthalmic conditions and a strong relationship has been established with non-arteritic anterior ischemic optic neuropathy (NAION). The incidence of glaucoma and stroke have also been significantly associated with OSA and are conditions that may also be seen by neuro-ophthalmologists. Patients with NAION have a significantly higher incidence of OSA and OSA diagnosis significantly increases the risk for NAION development. Non-compliance with continuous positive airway pressure (CPAP) in OSA patients has also been found to be a risk factor for fellow-eye involvement and there is increasing evidence to suggest that every patient with NAION should be formally evaluated with polysomnography. The relationship between OSA and idiopathic intracranial hypertension (IIH) has also been studied, but the relationship between these two conditions is less clear. There is insufficient evidence to recommend routine eye examinations in OSA patients for papilledema and conducting a sleep study for a newly diagnosed IIH patient should be left to the discretion of the clinician based on other symptoms and risk factors of OSA.

Is Obstructive Sleep Apnea Associated With Progressive Glaucomatous Optic Neuropathy?

PURPOSE

The purpose of this study was to evaluate the relationship between obstructive sleep apnea syndrome (OSAS) and glaucoma progression, and to examine the correlation between OSAS severity and rate of visual field (VF) loss.

METHODS

Patients with concurrent diagnoses of open-angle glaucoma and OSAS between 2010 and 2016 were identified. Enrollment criteria consisted of glaucomatous optic neuropathy and VF loss, ≥5 reliable VFs, ≥2 years of follow-up, and polysomnography (PSG) within 12 months of final VF. PSG parameters including apnea-hypopnea index (AHI) and oxygen saturation (SpO2) were collected. Eyes were classified as "progressors" or "nonprogressors" based upon event analysis using Glaucoma Progression Analysis criteria. Two-tailed t test comparisons were performed, and correlations between rates of VF loss and PSG parameters were assessed.

RESULTS

A total of 141 patients with OSAS and glaucoma were identified. Twenty-five patients (age 67.9±7.6 y) with OSAS (8 mild, 8 moderate, 9 severe) were enrolled. Eleven eyes (44%) were classified as progressors, and had more severe baseline VF loss (P=0.03). Progressors and nonprogressors had nonsignificantly different (P>0.05) age (69.9±8.7 vs. 66.4±6.6 y), follow-up (4.4±0.7 vs. 4.3±1.0 y), intraocular pressure (13.1±2.8 vs. 14.9±2.5 mm Hg), mean ocular perfusion pressure (49.7±5.5 vs. 48.8±9.0 mm Hg), AHI (31.3±18.6 vs. 26.4±24.0), body-mass index (27.8±5.5 vs. 28.8±5.6), and SpO2 (94.1±1.6% vs. 94.0±1.6%). AHI was not correlated with slopes of VF mean deviation (r, -0.271; P, 0.190) or pattern standard deviation (r, 0.211; P, 0.312), and no substantial increase in risk of progression was found with increase in AHI.

CONCLUSIONS

This study does not support a relationship between OSAS and glaucomatous progression. No correlation was observed between OSAS severity and rate of VF loss.

Prevalence and risk factors of glaucoma in an adult population from Shahroud, Iran

Purpose

To determine the prevalence of glaucoma and its risk factors in a 40- to 64-year-old Iranian population.

Methods

In this cross-sectional study, 6311 individuals between the ages of 40–64 years old in Shahroud, a northeastern city in Iran, were selected through multistage cluster sampling. All participants underwent eye exams, optometry, and imaging. They had stereoscopic optic disc photography, visual field evaluation, and their intraocular pressure (IOP) was measured by ophthalmologists before pupil dilation. Glaucoma was defined by the standardized criteria, offered by the International Society for Geographical and Epidemiological Ophthalmology (ISGEO).

Results

Of the 5190 people who participated in the study (82.2%), data from 4637 people were used in the analysis. The prevalence of glaucoma was 1.92% [95% confidence intervals (CI): 1.53–2.31]; 1.4% (95% CI: 0.96–1.84) in women and 2.62% (95% CI: 1.95–3.28) in men. Glaucoma prevalence was 0.9% in the 40–44 years age group, and significantly increased to 3.55% in the 60–64 years age group. In the multiple logistic regression model, age [odds ratio (OR) = 1.08, 95% CI: 1.05–1.12], IOP (OR = 1.04, 95% CI: 1.01–1.06), axial length (OR = 1.34, 95% CI: 1.1–1.63), corneal radius of curvature (OR = 2.76, 95% CI: 1.26–6.06), and corneal diameter (OR = 0.63, 95% CI: 0.46–0.87) showed significant statistical association with glaucoma.

Conclusions

The prevalence of glaucoma was considerably high at older ages. Major risk factors confirmed by this study included older age and high IOP. Certain ocular biometric components such as the axial length and the corneal radius of curvature must be noted as important glaucoma risk factors at younger ages.

Eye diseases associated with obstructive sleep apnea syndrome in an Asian population

Background: Sleep apnea syndrome is one of the leading causes of excessive daytime sleepiness. There is no literature exploring the prevalence of sleep-associated disorders in the eye of Asians with obstructive sleep apnea syndrome (OSA). Objective: Study the prevalence of eye abnormalities in Asian patients with OSA. Material and method: Asian patients with definite OSA diagnosis via the polysomnography were recruited into the study. Complete eye examination and special investigations were performed to define eye diseases: floppy eyelids, dry eyes, keratoconus, Fuchs’ endothelial dystrophy, recurrent corneal erosions, open-angle glaucoma, ophthalmoplegia, papilledema and optic neuropathy. Results: One-hundred Asian OSA patients were examined. We found that floppy eyelids, dry eyes, and normal tension glaucoma were more prevalent compared to the normal population. Abnormal endothelial change and papilledema were detected. Optic neuropathy and ophthalmoplegia were not found in this study, although some patients did have subnormal contrast sensitivity. Conclusion: There is a higher prevalence of floppy eyelids, dry eyes, and glaucoma in OSA patients. Complete eye examination is recommended in OSA patients to detect early eye abnormalities.

Risk of obstructive sleep apnea in open-angle glaucoma versus controls using the STOP-Bang questionnaire

OBJECTIVE

To compare the percentage of patients at risk for obstructive sleep apnea (OSA) in open-angle glaucoma (OAG) versus controls using the STOP-Bang questionnaire.

METHODS

This study used a cross-sectional survey. Patients with OAG and controls completed the STOP-Bang questionnaire-a validated tool to identify patients at high risk for OSA. Patients were considered at risk if they scored 3 or more points or at high risk for moderate/severe OSA if they scored 5 or more out of the maximum 8 points. Demographic information, medical history, and previous diagnosis of OSA were recorded. Details regarding the patients' glaucoma were obtained from their medical records.

RESULTS

A total of 437 patients with OAG and 441 controls were included. The mean STOP-Bang score was 3.01 ± 1.3 for the glaucoma group and 3.03 ± 1.4 for the control group (p = 0.92). There was no significant difference between the percentage of subjects considered at risk for OSA (62.7% OAG vs 59.4% controls, p = 0.37) or at high risk for moderate/severe OSA (12.6% OAG vs 16.5% controls, p = 0.1). Significantly more patients in the control group had a previous diagnosis of OSA (p = 0.01). More patients with OAG reported feeling tired compared with controls (p = 0.003). A risk/high risk for OSA was not associated with glaucoma severity, progression, intraocular pressure control, or glaucoma type.

CONCLUSIONS

Our results indicate that a risk or high risk for moderate/severe OSA as measured by the STOP-Bang questionnaire is not correlated with the presence or absence of glaucoma (regardless of the type), glaucoma severity, glaucoma progression, or IOP control.

Prevalence of primary open-angle glaucoma among patients with obstructive sleep apnea

OBJECTIVE

Our objective was to determine primary open-angle glaucoma (POAG) prevalence among obstructive sleep apnea (OSA) patients because the perioperative environment risks further damaging the optic nerve.

STUDY DESIGN

We analyzed a "convenience sample" referred by Sleep Medicine for oral appliances because of continuous positive airway pressure intolerance. We determined the aggregate prevalence of the 3 POAG subtypes-"classic" open-angle glaucoma (COAG), normal-tension glaucoma (NTG), and open-angle glaucoma suspect (OAGS)-among the index population and compared it with that of same hospital's general population. Similarly determined were associations between OSA severity levels (apnea-hypopnea index [AHI]) and POAG subtypes.

RESULTS

Among the study sample of 225 patients with OSA (96.4% male; mean age 58.5 ± 12.3 years), 47 (20.9%) had POAG, with a subtype distribution of COAG: 12 (25.5%), NTG: 8 (17.0%), and OAGS: 27 (57.4%). The POAG prevalence rate among medical center's general population was 2.5%, which was significantly less (P < .00001) than among those with comorbid OSA. Severity of the breathing disorder (AHI) failed to identify a significant correlation to any POAG subtype (P > .05).

CONCLUSION

The significant prevalence of POAG among OSA sufferers suggests need for preoperative consultations from an ophthalmologist to determine eye health and possibly an anesthesiologist to avoid potential vision loss.

Peripapillary retina nerve fiber layer thickness and macular ganglion cell layer thickness in patients with obstructive sleep apnea syndrome

PurposeTo investigate the association of the severity of obstructive sleep apnea syndrome (OSAS) with peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GC-IPL).Materials and methodsIn this cross-sectional study, 145 patients with OSAS and 40 healthy subjects were enrolled. OSAS patients were further divided into mild (n=50), moderate (n=36), and severe (n=59) OSAS groups according to their apnea-hypopnea index (AHI) values. Spectral-domain optical coherence tomography was used to measure the peripapillary RNFL and GC-IPL thicknesses.ResultsThere was no statistical difference between the RNFL thickness in OSAS and control groups (P>0.05). Both average GC-IPL and minimum GC-IPL thicknesses were significantly lower in severe OSAS group than in healthy controls (P<0.05 for both). There was a significant negative correlation between AHI and both average GC-IPL (r=-0.232, P=0.005) and minimum GC-IPL (r=-0.233, P=0.005) thicknesses.ConclusionsOur study results suggest that although RNFL thickness did not differ significantly between OSAS and control groups, ganglion cell layer thickness in OSAS patients is much lower than in healthy population. Ganglion cell thickness showed a significant correlation with the severity of OSAS.

Diseases of the retina and the optic nerve associated with obstructive sleep apnea

Many associations between ocular disorders and obstructive sleep apnea (OSA) have been studied, such as nonarteritic anterior ischemic optic neuropathy, glaucoma, papilledema, retinal vein occlusion, eyelid hyperlaxity, lower-eyelid ectropion and recurrent corneal erosions. The objective of this review is to synthetize the possible vascular disorders of the retina and the optic nerve associated with sleep apnea patients and to discuss the underlying pathophysiological hypotheses. Main mechanisms involved in the ocular complications of OSA are related to intermittent hypoxia, sympathetic system activation, oxidant stress, and deleterious effects of endothelin 1. The main evidence-based medicine data suggest that OSA should be screened in patients with ischemic optic neuropathy and diabetic retinopathy. The effect of OSA treatment and emerging therapies are discussed.

Twenty-four hour intraocular pressure monitoring with the SENSIMED Triggerfish contact lens: effect of body posture during sleep

PURPOSE

To determine the difference in relative intraocular pressure (IOP) measured by the SENSIMED Triggerfish (TF) contact lens in flat compared with 30° head-up sleeping positions in patients with progressive primary open-angle glaucoma or normotensive glaucoma, based on recent or recurrent disc haemorrhage.

DESIGN

Prospective, randomised, cross-over, open-label comparative study.

METHODS

IOP was monitored for 24 hours using TF on two separate sessions. Patients were randomly assigned to sleep flat one night and 30° head-up the other. Outputs in arbitrary units were obtained. Sleep and wake periods were defined as 22:00-6:00 and 8:00-22:00, respectively. Mean TF values during sleep and wake periods and wake-sleep and sleep-wake slopes were calculated for each session. TF output signals were compared between positions.

RESULTS

Twelve subjects completed the study. Significant mean positive slopes were noted during the sleep period for both positions (p<0.01). No significant differences in the TF mean values were observed between positions (p=0.51). Six (54%) subjects had mean TF values significantly higher during the flat supine session, while four (36%) subjects had higher values during the head-up session. A significant increase in Goldmann IOP (p=0.001) and TF (p=0.02) measurements were observed after 24 hours of TF wear ('drift phenomenon').

CONCLUSIONS

Sleep position affects IOP as measured by TF in some patients with progressive glaucoma. The upward drift in TF output detected in >50% of the subjects requires further investigation to establish whether the increased output values over time are an artefact induced by the TF or a real change in IOP.

TRIAL REGISTRATION NUMBER

NCT01351779.

Changes in Retinal Nerve Fiber Layer Thickness in Obstructive Sleep Apnea/Hypopnea Syndrome: A Meta-Analysis

PURPOSE

To evaluate and compare changes in retinal nerve fiber layer (RNFL) thickness in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).

METHODS

The Cochrane Library, Medline, and Embase were screened using our key words. Results were carefully reviewed to ensure that the included studies met the inclusion/exclusion criteria, and the quality of the studies was assessed using the Newcastle-Ottawa Scale. All included studies categorized patients with OSAHS into 3 groups (mild, moderate, and severe), and measured average and 4-quadrant (temporal, superior, nasal, and inferior) RNFL thickness. All studies included a healthy control group. The weighted mean differences and 95% confidence intervals were calculated for the continuous outcomes.

RESULTS

Ten case-control studies were included in the meta-analysis, consisting of a total of 811 OSAHS group and 868 healthy eyes. A meta-analysis of the data showed that the average RNFL thicknesses in the mild, moderate, and severe OSAHS groups were significantly decreased compared to healthy controls. Additionally, RNFL thickness was significantly reduced in all but the temporal quadrant in the moderate and severe OSAHS groups when compared to healthy controls.

CONCLUSIONS

On the basis of these results, we suggest that peripapillary RNFL thickness as measured by optical coherence tomography could be a useful tool to monitor and assess the severity of OSAHS in patients. Further studies are required in order to differentiate these RNFL changes from glaucomatous changes. This has not been properly examined in any of the studies we were able to identify.

Meta-Analysis of Association of Obstructive Sleep Apnea With Glaucoma

OBJECTIVES

Previous studies suggested that obstructive sleep apnea (OSA) was associated with glaucoma. However, data on this issue are controversial. This study aims to use meta-analysis to determine whether OSA is related to glaucoma.

MATERIALS AND METHODS

We searched PubMed, Embase, the Cochrane library, the Web of Science, and the Chinese BioMedical Literature Database disk databases up to November 20, 2014 for related literature. The association of OSA with glaucoma was assessed by odds ratio (OR) with 95% confidence interval (CI) as the effect size. Then subgroup analysis was performed according to area and glaucoma type.

RESULTS

Six primary studies (3 cohort study and 3 case-control studies) were included in this meta-analysis involving 2,288,701 participants. There was a significant association between OSA and glaucoma (adjusted-effect summary for case-control studies OR=2.46; 95% CI, 1.32-4.59, P=0.005) (adjusted-effect summary for cohort studies OR=1.43; 95% CI, 1.21-1.69, P=0.000). There was no significant publication bias.

CONCLUSION

OSA was a risk factor for glaucoma. A large number of studies is needed to explore the mechanisms that link OSA with glaucoma.

Associations between obstructive sleep apnoea, primary open angle glaucoma and age-related macular degeneration: record linkage study

BACKGROUND

Primary open angle glaucoma (POAG) is thought to be associated with obstructive sleep apnoea (OSA) but previous studies are conflicting and have methodological limitations. This potential relationship has implications for investigation and treatment strategies, and may provide insights into disease pathogenesis. The relationship between OSA and age-related macular degeneration (AMD) is unknown.

METHODS

A sleep apnoea cohort of 67 786 people was constructed from linked English hospital episode statistics (1999-2011). We compared this cohort with a reference cohort (2 684 131 people) for rates of subsequent POAG and AMD. A POAG cohort (comprising 87 435 people) and an AMD cohort (248 408 people) were also constructed and compared with the reference cohort for rates of subsequent sleep apnoea. All analyses were restricted to people aged 55 and over and, within this age range, were age standardised using 5-year age groups.

RESULTS

Risk of POAG following sleep apnoea was not elevated: the rate ratio for POAG was 1.01 (95% CI 0.85 to 1.19). Similarly, the risk of sleep apnoea following POAG was not elevated: the rate ratio was 1.00 (0.86 to 1.17). These findings held true across subgroup analysis according to sex and age group. By contrast, the risk of AMD following sleep apnoea was significantly elevated, with rate ratio 1.44 (1.32 to 1.57).

CONCLUSIONS

Although plausible mechanisms exist to consider a link between OSA and POAG, the two conditions are not positively associated. This holds true in either temporal direction. By contrast, OSA is positively associated with AMD. While potential confounding factors may contribute, obesity does not appear sufficient to explain this association.

Glaucoma and its association with obstructive sleep apnea: A narrative review

Obstructive sleep apnea (OSA) is one of the systemic risk factors for glaucoma which causes irreversible visual field (VF) damage. We reviewed the published data of all types of studies on the association between these two conditions and papers regarding functional and structural changes related to glaucomatous damage using Scopus, web of science, and PubMed databases. There is evidence that the prevalence of glaucoma is higher in OSA patients, which independent of intraocular pressure (IOP). Studies have reported thinning of retinal nerve fiber layer (RNFL), alteration of optic nerve head, choroidal and macular thickness, and reduced VF sensitivity in patients of OSA with no history glaucoma. A negative correlation of apnea-hypopnea index with RNFL and VF indices has been described in some studies. Raised IOP was noted which is possibly related to obesity, supine position during sleep, and raised intracranial pressure. Diurnal fluctuations of IOP show more variations in OSA patients before and after continuous positive airway pressure (CPAP) therapy when compared with the normal cases. The vascular factors behind the pathogenesis include recurrent hypoxia with increased vascular resistance, oxidative stress damage to the optic nerve. In conclusion, comprehensive glaucoma evaluation should be recommended in patients with OSA and should also periodically monitor IOP during CPAP treatment which may trigger the progression of glaucomatous damage.

Effects of Use of a Continuous Positive Airway Pressure Device on Glaucoma

Background

The aim of this study was to investigate the prevalence of glaucoma in obstructive sleep apnea syndrome (OSAS) and to determine the efficacy of the equipment used in the treatment of this disease.

Material/Methods

In this cross-sectional study, 38 patients with OSAS used the continuous positive airway pressure (CPAP) device (Group 1) and 32 patients with OSAS refused CPAP device (Group 2). Thirty-six patients did not have OSAS (Group 3).

Results

Patient age, gender, height, weight, and neck circumference did not differ among groups (p>0.05); and the apnea-hypopnea index (AHI) and respiratory disturbance index (RDI) values did not differ between Groups 1 and 2 (p>0.05). Vision and pachymetric values did not differ among groups (p>0.05). The IOP was significantly higher in Group 2 than in Group 1 (p<0.05) but did not differ between Groups 1 and 3 (p>0.05). The fundus C/D ratio was significantly higher (p<0.05) in Group 2 than in the other groups but did not differ between Groups 1 and 3 (p>0.05). In Group 1, 2, and 3, 5.2%, 12.5%, and 0%, respectively, of patients had glaucoma.

Conclusions

OSAS should be considered a significant risk factor for glaucoma. Eye tests may help to identify individuals with undiagnosed OSAS, and such testing of patients with diagnosed OSAS may allow early detection of glaucoma and referral of such patients for CPAP therapy to prevent development of complications.

The effect of nocturnal CPAP therapy on the intraocular pressure of patients with sleep apnea syndrome

PURPOSE

Few studies have documented that nocturnal continuous positive airway pressure (CPAP) therapy is associated with an increase in intraocular pressure (IOP) in patients with severe obstructive sleep apnea syndrome (OSAS). We re-examined the effect of CPAP therapy on the IOP of OSAS patients.

METHODS

The IOP of two different groups of newly diagnosed OSAS patients was compared at their first sleep lab exam without CPAP treatment (non-CPAP treated group; n = 20) and at the second sleep lab exam with CPAP treatment (CPAP treated group; n = 31). The sleep lab exam (sleep period: from 11:00 p.m. until 6:00 a.m.) included IOP measurements, a complete ophthalmologic exam, and nocturnal hemodynamic recordings. The IOP was measured serially using rebound tonometer (IOP; ICARE® PRO) performed while in sitting and supine positions before, during, and after the sleep period. We compared the difference in IOP of CPAP and non-CPAP groups.

RESULTS

The mean IOP of the CPAP and non-CPAP groups measured in sitting position before the sleep period was 13.33 ± 2.04 mmHg and 14.02 ± 2.44 mmHg, respectively (p = 0.9). Assuming a supine position for 1 minute significantly increased the IOP by 1.93 mmHg and 2.13 mmHg for both the non-CPAP and CPAP groups (paired t-test; p = 0.02, p = 0.001 respectively), but this IOP rise showed no difference between the two groups. The IOP increased significantly further after 7 hours of sleep in the supine position, and the mean IOP of the CPAP and non-CPAP groups was 19.2 ± 5.68 mmHg and 19.69 ± 5.61 mmHg respectively (independent t-test; p = 0.74). The rise in IOP for both groups was not correlated with any hemodynamic parameters. Three OSAS patients with glaucoma treated with CPAP had mean IOP of 23.75 mmHg after 7 hours of sleep.

CONCLUSIONS

OSAS patients have a significant rise in IOP during the sleep period when comparing measurements before and after the sleep period; however, CPAP therapy did not affect the measured IOP. The presented findings suggest that in terms of IOP, CPAP is safe for non-glaucomatous patients, but this may not hold true for glaucomatous patients.

Thickness alterations of retinal nerve fiber layer in children with sleep-disordered breathing due to adenotonsillar hypertrophy

OBJECTIVE

This study is designed to assess whether hypoxia which is caused by apnea and hypopnea episodes, has an effect on retinal nerve fiber layer (RNFL) thickness, using optical coherence tomography (OCT) in pediatric patients with Adenotonsillar hypertrophy (ATH).

METHODS

Fifty-seven children patient with AHT, and 31 healthy non-AHT children (between 6 and 12 ages) were enrolled in this study. Obstructive symptoms of the patients with ATH were assessed by using OSA-18 survey. The patients were divided into 2 groups as mild (>60 and <80) and severe (>80) OSAS patients, according to OSA-18 survey total scores. RNFL thickness, in the four quadrants (superior, nasal, inferior and temporal) patient's both eyes, was measured by optical coherence tomography. RNFL parameters of control and patient groups were compared. Correlation between OSA survey scores and RNFL thickness of the patient groups were examined.

RESULTS

A positive correlation was found between ages and RNLF thickness of all subjects enrolled in this study (r=+0.107, p<0.05). And also a poor correlation was found between OSA-18 survey scores and RNFL parameters in patient group (between -0.031 and +0.016 at right and left eyes, p>0.05). No statistically significant alteration in RNFL thickness was found between the patient and control groups (p>0.05).

CONCLUSION

Age range (6-12) of the patients with ATH in our study considers that possible OSAS time was not long enough to affect RNLF thickness. Remembering the risk of optic injury development in children with ATH (in a long term), tonsillectomy and/or adenoidectomy operations shouldn't be delayed.

[Prevalence of glaucoma in obstructive sleep apnea]

BACKGROUND

A causal relationship between glaucoma and obstructive sleep apnea has been postulated in several clinical studies but also refuted by others. The aim of this study was to determine the prevalence of glaucoma in a cohort of patients with well-established obstructive sleep apnea in comparison to the published data on this topic.

METHODS

A total of 100 consecutive patients (male:female  80:20, mean age 59 ± 11 years SD) with polysomnographically established obstructive sleep apnea underwent an ophthalmological examination including tonometry, static perimetry and dilated fundus photography. Visual fields and fundus photographs of the patients were classified as glaucomatous or non-glaucomatous by two independent examiners.

RESULTS

The prevalence of glaucoma in the study patients was 2 % which corresponded to the published prevalence of glaucoma in the normal population. Intraocular pressure did not correlate with the respiratory index, body mass index or sex.

CONCLUSION

The data from this study shed doubt on a causal relationship between obstructive sleep apnea and glaucoma.

Association between glaucoma and obstructive sleep apnea syndrome: a meta-analysis and systematic review

Background

Obstructive sleep apnea syndrome (OSAS) is a common disease that increases the risk of diabetes, heart disease, and stroke. However, studies of an association between OSAS and glaucoma neuropathy have reported controversial findings.

Objective

The main purpose of this study was to evaluate whether a significant association exists between OSAS and glaucoma by performing a meta-analysis of previous studies.

Methods

A comprehensive literature search using the PubMed and Embase databases was performed to identify cross-sectional, case-control, and cohort studies related to the topic. We estimated a pooled odds ratio (OR) for the association between OSAS and glaucoma, by a fixed- or random-effects model.

Results

In total, 16 studies with 2,278,832 participants met the inclusion criteria: one retrospective cohort study reported an adjusted hazard ratio of glaucoma of 1.67 (95% CI = 1.30–2.17). Using a fixed-effects model, the pooled OR of six case-control studies was 1.96 (95% CI = 1.37 2.80). A significant association was also identified in a meta-analysis of nine cross-sectional studies using a random-effects model, which showed a pooled OR of 1.41 (95% CI = 1.11 1.79). However, the reported pooled estimates for case control studies and cross-sectional studies were based on unadjusted ORs.

Conclusions

Our results suggest that OSAS is associated with the prevalence of glaucoma. However, this result was based only on unadjusted estimates. Prospective cohort studies designed to take into consideration potential confounders, or examination of data from interventional trials to determine whether a reduction in OSAS status is associated with a reduced incidence of glaucoma, are needed to clarify whether OSAS is an independent risk factor for glaucoma.

Obstructive sleep apnea and optic neuropathy: is there a link?

Over the last decade, there has been an emerging interest in the link between obstructive sleep apnea (OSA) and ocular health. Though the evidence for OSA playing a role in cerebrovascular disease risk seems clear, the same cannot be said for optic neuropathies. The association between OSA and glaucoma or non-arteritic anterior ischemic optic neuropathy (NAION) has been postulated to be secondary to direct hypoxia or mechanisms of optic nerve head vascular dysregulation. Papilledema and increased intracranial pressure have also been reported in OSA and are thought to be due to increased cerebral perfusion pressure and cerebral venous dilation secondary to hypoxia and hypercapnia. This article reviews the evidence for possible pathophysiological links between OSA and optic nerve pathology. The epidemiologic and clinical evidence for an association, direct or indirect, between OSA and glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), and papilledema or idiopathic intracranial hypertension is presented.

A prospective photographic study of the ocular fundus in obstructive sleep apnea

BACKGROUND

The prevalence of optic nerve and retinal vascular changes within the obstructive sleep apnea (OSA) population are not well-known, although it has been postulated that optic nerve ischemic changes and findings related to an elevated intracranial pressure may be more common in OSA patients. We prospectively evaluated the ocular fundus in unselected patients undergoing overnight diagnostic polysomnography (PSG).

METHODS

Demographic data, medical/ocular history, and nonmydriatic fundus photographs were prospectively collected in patients undergoing PSG at our institution and reviewed for the presence of optic disc edema for which our study was appropriately powered a priori. Retinal vascular changes were also evaluated. OSA was defined using the measures of both sleep-disordered breathing and hypoxia.

RESULTS

Of 250 patients evaluated in the sleep center, fundus photographs were performed on 215 patients, among whom 127 patients (59%) had an apnea/hypopnea index (AHI) ≥ 15 events per hour, including 36 with severe OSA. Those with AHI <15 served as the comparison group. None of the patients had optic disc edema (95% confidence interval [CI]: 0%-3%). There was no difference in rates of glaucomatous appearance or pallor of the optic disc among the groups. Retinal arteriolar changes were more common in severe OSA patients (odds ratio: 1.09 per 5 unit increase in AHI; 95% CI, 1.02-1.16; P = 0.01), even after controlling for mean arterial blood pressure.

CONCLUSIONS

We did not find an increased prevalence of optic disc edema or other optic neuropathies in our OSA population. However, retinal vascular changes were more common in patients with severe OSA, independent of blood pressure.

Relationship between severity of obstructive sleep apnea syndrome and retinal nerve fiber layer thickness

PURPOSE

To determine whether there is a significant correlation among the peripapillary retinal nerve fiber layer (RNFL) thickness, foveal thickness, total macular volume, and severity of obstructive sleep apnea syndrome.

DESIGN

Prospective study.

METHODS

We studied 124 consecutive subjects who underwent polysomnography. Optical coherence tomography (OCT) was used to measure the peripapillary RNFL, foveal thickness, and total macular volume. The Pearson correlation coefficient was used to determine the relationship between the apnea-hypopnea index and OCT and other parameters. Multiple regression analysis was used to determine the independent factors for the RNFL sectors that were the most strongly correlated with the apnea-hypopnea index.

RESULTS

The apnea-hypopnea index was significantly and negatively correlated (right eye, r = -0.31, P = 0.0004; left eye, r = -0.39, P < 0.0001) with the nasal RNFL thickness (Pearson correlation analysis). The foveal thickness and total macular volume were not correlated. The intraocular pressure, body mass index, plaque score, and incidence of hypertension were negatively correlated, and the lowest oxygen saturation and mean oxygen saturation were positively correlated with the nasal RNFL thickness in the left eye. Multiple regression analysis showed that the apnea-hypopnea index and age were independent contributors to the nasal RNFL thickness in the left eye (apnea-hypopnea index, standard regression coefficient, -0.30, t value, -2.76, P = 0.007; age, -0.24, -2.36, 0.02, respectively). The nasal RNFL thickness in both eyes decreased significantly based on the severity of the obstructive sleep apnea syndrome.

CONCLUSION

Exacerbation of obstructive sleep apnea syndrome may produce unique retinal neurodegenerative disorders that decrease the nasal RNFL thickness.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) and glaucomatous optic neuropathy

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is becoming widely accepted as a risk factor for glaucoma. We discuss the proposed mechanism involved in the pathogenesis of glaucoma in OSAHS, and review the published data on the association between these two conditions, as well as papers regarding functional and structural tests related with glaucomatous damage. There is increasing evidence that the prevalence of glaucoma is higher in OSAHS patients, especially in those with severe disease with apnea-hypopnea index (AHI) >30, and also that sleep disorders may be more frequent in patients with glaucoma, especially in those with normal tension glaucoma (NTG). Several ophthalmic signs and symptoms have been associated with this condition. Raised intraocular pressure (IOP), possibly related to increased body mass index, thinning of retinal nerve fiber layer (RNFL), and alteration of visual field (VF) indices has been demonstrated in many studies, in patients with no history of glaucoma or evidence of glaucomatous changes in the ophthalmic examination. A correlation of AHI with RNFL and VF indices has been described in some studies. Finally, corneal thinning, suspicious glaucomatous disc changes and anomalies in electrophysiological tests such as multifocal visual evoked potential have been described in patients with OSAHS, even in patients with normal findings in the optic nerve and VF, suggesting subclinical optic nerve involvement not detectable in conventional ophthalmic examinations. The pathogenesis of optic nerve involvement has been related to vascular and mechanical factors. Vascular factors include recurrent hypoxia with increased vascular resistance, autonomic deregulation, oxidative stress and inflammation linked to hypoxia and subsequent reperfusion, decreased cerebral perfusion pressure and direct hypoxic damage to the optic nerve. Proposed mechanical factors include increased IOP at night related to supine position and obesity, raised intracranial pressure and elastic fiber depletion in the lamina cribosa and/or trabeculum. In conclusion, ophthalmic evaluation should be recommended in patients with severe OSAHS, and the presence of sleep disorders should be investigated in patients with glaucoma, especially in NTG patients and in those with progressive damage despite controlled IOP, as treatment with continuous positive airway pressure may contribute to stabilizing the progression of glaucomatous damage.

Changes of visual field and optic nerve fiber layer in patients with OSAS

BACKGROUND

The prevalence of primary open-angle glaucoma (POAG) increases in obstructive sleep apnea syndrome (OSAS). OSAS could increase cerebrospinal fluid pressure (CSFP) and binocular papilledema.

METHODS

In this cross-sectional study, intraocular pressure (IOP), CSFP, mean deviation (MD), pattern standard deviation (PSD), optic disc indices, and retinal nerve fiber layer (RNFL) were compared among four groups with different extents of OSAS. Regression analysis was performed to correlate MD, PSD, and RNFL to polysomnography (PSG) index. For subgroups with severe OSAS, IOP and CSFP were compared. The prevalence of POAG was calculated.

RESULTS

The severe OSAS had a significantly higher CSFP than the other three groups (p = 0.002, 0.036, and 0.017). Both moderate and severe groups showed significantly higher IOP than control group (p = 0.022 and 0.001). MD was correlated with average oxygen saturation (MSaO2) (p = 0.001). PSD was correlated with oxygen desaturation index (ODI) (p = 0.004). Significant differences were found in nasal RNFL and inferior RNFL among the four groups (p = 0.013, p = 0.004). Nasal RNFL correlated with the ODI (p = 0.048). For severe group, compared to normal RNFL group, CSFP was significantly lower in the thinned RNFL group (p = 0.039) and higher in the thickened RNFL group (p = 0.034). Totally, the prevalence of POAG was 5.49 %.

CONCLUSIONS

OSAS had a high prevalence of POAG. Visual field was damaged and the RNFL was thinned. Due to diverse CSFP, RNFL changed differently in the patients with severe OSAS.

Snoring and glaucoma

Purpose

To examine a potential association between snoring and glaucoma in a population-based setting.

Methods

The population-based Beijing Eye Study 2011 included 3468 subjects with an age of 50+ years. The participants underwent a detailed ophthalmic examination. Glaucoma was determined according to the ophthalmoscopic appearance of the optic nerve head. Snoring assessed in an interview was graded into “severe snoring”, “moderate snoring”, and “no snoring”.

Results

Data on snoring and glaucoma were available for 3146 subjects. Snoring was reported for 1787 (66.8%) subjects, with moderate snoring reported for 1384 (44.0%) subjects and severe snoring for 403 (12.8%) subjects. In multivariate analysis, prevalence of severe snoring was significantly associated with male gender (P = 0.002; regression coefficient B: 0.36; Odds ratio (OR): 1.44 (95% confidence interval (CI): 1.14, 1.81)), higher body mass index (P<0.001; B: 0.12; OR: 1.13 (95%CI: 1.09, 1.16)), higher systolic blood pressure (P<0.001; B: 0.01; OR: 1.01 (95%CI: 1.005, 1.02)), younger age (P = 0.007; B: −0.018; OR: 0.98 (95%CI: 0.97, 0.995)), and higher cognitive function (P = 0.03; B: 0.04; OR: 1.04 (95%CI: 1.004, 1.08)), however it was not significantly associated with the prevalence of open-angle glaucoma (P = 0.10; B: −0.63; OR: 0.53 (95%CI: 0.25, 1.12)). Prevalence of severe snoring was neither significantly associated with the prevalence of angle-closure glaucoma (P = 0.65), retinal vein occlusions (P = 0.24), neuroretinal rim area (P = 0.19), retinal nerve fiber layer thickness (P = 0.16) nor vertical cup/disc ratio (P = 0.64).

Conclusions

Severe snoring was not significantly associated with the prevalence of open-angle glaucoma, angle-closure glaucoma or retinal vein occlusions after adjustment for age, gender, body mass index, systolic blood pressure and cognitive function score. Our population-based study did not reveal that snoring was a risk factor for glaucoma and thus did not provide a reason to assess or to treat snoring in patients with glaucoma.

The evaluation of retinal nerve fiber layer thickness in patients with obstructive sleep apnea syndrome

Aim. To evaluate the retinal nerve fiber layer (RNFL) thickness in patients with obstructive sleep apnea syndrome (OSAS) by optical coherence tomography (OCT). Materials and Method. We studied 43 new diagnosed OSAS patients and 40 healthy volunteers. Patients underwent an overnight sleep study in an effort to diagnose and determine the severity of OSAS. RNFL analyses were performed using Stratus OCT. The average and the four-quadrant RNFL thickness were evaluated. Results. There was no difference between the average and the four-quadrant RNFL thickness in OSAS and control groups. There was no correlation between apnea-hypopnea index and intraocular pressure. Body mass index of patients with moderate and severe OSAS was significantly higher in patients with mild OSAS. Conclusion. Mean RNFL thickness did not differ between the healthy and the OSAS subjects, however, the parameters were more variable, with a larger range in OSAS patients compared to controls.

Is there a relationship between sleep apnea and central corneal thickness?

PURPOSE

The objective of this study was to determine the central corneal thickness (CCT) measurements in patients with Sleep Apnea Syndrome (SAS) and the relationship between the severity of SAS and minimal arterial oxygen saturation (min. SpO2) with respect to CCT.

MATERIALS AND METHODS

Two hundred and fourteen eyes of 107 patients (58 males, 49 females) who were diagnosed as SAS and 80 eyes of 40 healthy subjects (20 males, 20 females) were included in the study. The SAS patients were divided into subgroups according to their Apnea-Hypopnea Index (AHI) values as: AHI values between 5 and 15 as subgroup 1, between 15 and 30 as subgroup 2, and the values ≥30 as subgroup 3. The CCT was measured by an ultrasonic pachymetric system. Statistical analyses were an analysis of variance test and, for post-hoc analysis, the Dunnett C test.

RESULTS

Mean age was 52.5 ± 10.96 years in the study group, and 40.7 ± 10.14 years in the control group. There were 58 (54.2%) males and 49 (45.8%) females in the study group, and 20 (50%) males and 20 (50%) females in the control group. Mean CCT values were 526.65 ± 25.06, 525.26 ± 29.25, 512.93 ± 43.20 and 539.90 ± 17.28 in subgroup 1, subgroup 2, subgroup 3 and the control group, respectively. There were no statistically significant differences between gender and age groups with respect to CCT (p > 0.05). When the mean CCT values of each subgroups were compared with the control group, the differences were statistically significant (p < 0.05). There was a negative correlation between CCT and AHI values and a positive correlation between CCT and min. SpO2 values.

CONCLUSIONS

CCT measurements differ significantly in patients with SAS compared with healthy control subjects. It should be taken into consideration that SAS may reduce CCT over time and that CCT should be measured in each ophthalmic examination.

Obstructive sleep apnea and increased risk of glaucoma: a population-based matched-cohort study

PURPOSE

Previous studies had reported an increased prevalence of glaucoma in patients with obstructive sleep apnea (OSA). However, the risk of open-angle glaucoma (OAG) among patients with OSA remains unclear. Using a nationwide, population-based dataset in Taiwan, this study aimed to examine the prevalence and risk of OAG among patients with OSA during a 5-year follow-up period after a diagnosis of OSA.

DESIGN

A retrospective, matched-cohort study.

PARTICIPANTS AND CONTROLS

This study used data sourced from the Longitudinal Health Insurance Database 2000. We included 1012 subjects with OSA in the study cohort and randomly selected 6072 subjects in the comparison group.

METHODS

Each subject in this study was individually traced for a 5-year period to identify those subjects who subsequently received a diagnosis of OAG. Cox proportional hazards regression was performed to calculate the 5-year risk of OAG between the study and comparison cohorts.

MAIN OUTCOME MEASURES

The incidence and risk of OAG between the study and comparison groups.

RESULTS

During the 5-year follow-up period, the incidence rate per 1000 person-years was 11.26 (95% confidence interval [CI], 8.61-14.49) and 6.76 (95% CI, 5.80-7.83) for subjects with and without OSA, respectively. After adjusting for monthly income, geographic region, diabetes, hypertension, coronary heart disease, obesity, hyperlipidemia, renal disease, hypothyroidism, and the number of outpatient visits for ophthalmologic care during the follow-up period, stratified Cox proportional hazards regression revealed that the hazard ratio for OAG within the 5-year period for subjects with OSA was 1.67 (95% CI, 1.30-2.17; P<0.001) that of comparison subjects.

CONCLUSIONS

Our results suggest that OSA is associated with an increased risk of subsequent OAG diagnosis during a 5-year follow-up period.

FINANCIAL DISCLOSURES(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Retinal nerve fiber thickness is reduced in sleep apnea syndrome

OBJECTIVE

To investigate the prevalence of glaucoma, visual field abnormalities, as well as changes in retinal nerve fiber layer in patients with obstructive sleep apnea syndrome (OSAS).

METHODS

In this cross-sectional study, 51 patients with OSAS were included. Based on apnea hypopnea index (AHI), there were 26, 6 and 19 cases of severe (AHI⩾30), moderate (15⩽AHI<30), and mild (5⩽AHI<15) OSAS, respectively. The control group was matched for age, sex and body mass index. Prevalence of glaucoma and ocular hypertension as well as the following values were assessed and compared between two groups: best-corrected visual acuity, intraocular pressure, central corneal thickness (CCT), cup:disk ratio, mean deviation (MD), pattern standard deviation, and retinal nerve fiber layer (RNFL) parameters using glaucoma diagnosis measurement (GDx).

RESULTS

Seven eyes (6.7%) had intraocular pressure (IOP)>21mmHg; of these, four eyes (3.9%) had glaucoma. No significant difference was detected in CCT between the two groups. IOP was significantly higher in the OSAS group before (p<0.001) and after (p<0.001) correcting for CCT. There was a significant difference between groups in MD and most GDx parameters including DISK (temporal-superior-nasal-inferior-temporal) average (p=0.002), superior average (p=0.05) and nerve fiber indicator (NFI) (p=0.03), where those in the patient group showed lower values. There was a significant positive correlation between AHI and both IOP and NFI.

CONCLUSIONS

OSAS patients had a higher prevalence of glaucoma and ocular hypertension. OSAS patients also had higher IOP, worse visual field indices, and lower RNFL parameters compared with the control group.

Glaucoma and obstructive sleep apnoea syndrome

Glaucoma is increasingly recognized as a manifestation of both ocular and systemic risk factors. A number of disorders associated with reduced blood flow and ischaemia, collectively termed vascular risk factors, such as migraine, Raynaud's phenomenon, atrial fibrillation and reduced nocturnal blood pressure, lead to decreased ocular perfusion pressure. During sleep, alterations occur in cardiovascular physiology that are balanced by autoregulation to maintain homeostasis. However, in obstructive sleep apnoea (OSA), the normal physiological balance is upset. A potentially modifiable risk factor, OSA has been increasingly associated with glaucoma independent of intraocular pressure. OSA may alter blood flow to the optic nerve head and, in combination with other predisposing factors, lead to decreased ocular perfusion pressure. This in turn may directly affect the optic nerve or it may indirectly increase its susceptibility to other insults. The purpose of this review is to shed light on the association between OSA and glaucoma.