Ocular findings in sleep apnoea patients using continuous positive airway pressure

Associations Between Obstructive Sleep Apnea Syndrome, Dry Eye Disease, and CPAP Usage Among Taiwanese Patients: A Retrospective Analysis

Study Objectives

To evaluate the association between obstructive sleep apnea (OSA) and dry eye disease (DED) and analyze the impact of Continuous Positive Airway Pressure (CPAP) on DED.

Methods

This is a retrospective population-based case-control study. Patients who underwent polysomnography in Taiwan from March 1, 2009, to March 1, 2020, were identified from the database of a sleep center. Patients who were diagnosed with keratoconjunctivitis sicca or tear film insufficiency were included. Patients without data from Schirmer's test, lacking tear break-up time values, or with a history of refractive surgery, Sjögren's syndrome, ocular injuries, or a disability in eyelid closure were excluded. All patients with DED enrolled had DED in both eyes. OSA severity between patients with and without DED was compared.

Results

In total, 86 patients with DED and 86 age-matched patients without DED were enrolled. Significant differences in apnea-hypopnea index values (patients with DED: 29.1 ± 23.4, patients without DED: 17.9 ± 20.2, P < 0.001), OSA severity (P < 0.001), and lowest oxygen saturation (P = 0.040) between patients with and without DED were observed. A multivariate logistic regression model indicated that the use of CPAP was independently associated with DED after adjustments for OSA severity. Patients undergoing CPAP were at greater risk of developing DED than those not undergoing CPAP (Odds ratio: 3.93, 95% confidence interval: 1.47-10.49, P = 0.006).

Conclusion

OSA severity is associated with DED and might be attributed to the use of CPAP.

Looking beyond in Sleep Medicine Practice: Effect of OSA Management in Floppy Eyelid Syndrome - A Case Report

Obstructive Sleep Apnea Syndrome (OSA) is a common sleep disorder characterized by recurrent episodes of partial or complete upper airway obstruction during sleep. Floppy Eye Syndrome (FES) is a condition in which the upper eyelids easily evert with upward traction due to underlying tarsal plate laxity and is associated with chronic, reactive papillary conjunctivitis; this causes the eye to be vulnerable to discomfort and visual symptoms. A 49-year-old man with an 8-year history of snoring, sleep fragmentation, and daytime sleepiness was admitted as an outpatient in our sleep clinic. The patient had complied ocular symptoms such as burning eyes, redness, and irritative ocular symptoms in the past five years, arising upon waking up. The symptoms did not regress with the use of artificial tears and proper ointment. The patient was diagnosed with OSA and began using continuous positive airway pressure (CPAP). CPAP therapy significantly corrected the symptoms of FES associated with OSA . This would help to sensibilize ocular findings in patients with OSA and identify hidden sleeping diseases needing a more appropriate investigation and possible treatment. We must look beyond our approach to sleep clinic patients and avoid being kept to the common symptoms patients represent.

Effects of full-thickness wedge resection on ocular surface and in vivo confocal microscopy findings in floppy eyelid syndrome patients

OBJECTIVE

To evaluate the effect of full-thickness wedge resection (FTWR) on ocular surface and in vivo confocal microscopy (IVCM) findings in patients with floppy eyelid syndrome (FES).

METHODS

The study included two groups: a surgical treatment (ST) group (26 eyes) consisting of patients who underwent FTWR surgery, and a conservative treatment (CT) group (30 eyes). Pre-treatment and post-treatment ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescein staining (CFS), IVCM findings along with the body mass index (BMI), FES grade, the presence and the treatment of obstructive sleep apnea syndrome (OSAS) were recorded and compared between the groups.

RESULTS

The groups were comparable in terms of BMI, FES grade, and OSAS data. After six months, TBUT in the ST group significantly increased to 12.92 ± 1.15, compared to 8.10 ± 1.60 in the CT group (p = 0.000). The CFS and OSDI scores were significantly lower in the ST group (0.15 ± 0.37, 18.0 ± 8.3, respectively) compared to the CT group (0.90 ± 0.61, 27.3 ± 9.3, respectively) (p = 0.000). IVCM analysis revealed a significant decrease in dendritic cell count (ST: 22.0 ± 12.4, CT: 39.5 ± 15.1, p = 0.000) and nerve tortuosity (ST: 1.38 ± 0.64, CT: 2.00 ± 0.59, p = 0.000), with a significant increase in total nerve density (ST: 4.27 ± 0.83, CT: 3.57 ± 0.90, p = 0.002) in the ST group compared to the CT group after six months.

CONCLUSION

In our retrospective cohort, FTWR surgery was shown to be an effective and reliable surgical treatment for FES, improving both ocular surface and IVCM findings. Patients with moderate to severe stages of FES not responding to conservative treatment may benefit from eyelid tightening.

Ocular manifestations of obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

The association of obstructive sleep apnea (OSA) with development of eye diseases is unclear. This current systematic review and meta-analysis attempts to summarize and analyze associations between OSA and ocular disorders in the literature.

METHODS

PubMed, EMBASE, Google Scholar, Web Of Science, and Scopus databases were searched from 1901 to July 2022 in accordance with the Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA). Our primary outcome assessed the association between OSA and the odds of developing floppy eyelid syndrome (FES), glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), keratoconus (KC), idiopathic intracranial hypertension (IIH), age-related macular degeneration (AMD), and central serous chorioretinopathy (CSR) through odds ratio calculated at the 95% confidence interval.

RESULTS

Forty-nine studies were included for systematic review and meta-analysis. The pooled OR estimate was highest for NAION [3.98 (95% CI 2.38, 6.66)], followed by FES [3.68 (95% CI 2.18, 6.20)], RVO [2.71(95% CI 1.83, 4.00)], CSR [2.28 (95% CI 0.65, 7.97)], KC [1.87 (95% CI 1.16, 2.99)], glaucoma [1.49 (95% CI 1.16, 1.91)], IIH [1.29 (95% CI 0.33, 5.01)], and AMD [0.92 [95% CI 0.24, 3.58] All observed associations were significant (p < 0.001) aside from IIH and AMD.

CONCLUSION

OSA is significantly associated with NAION, FES, RVO, CSR, KC, and glaucoma. Clinicians should be informed of these associations so early recognition, diagnosis, and treatment of eye disorders can be addressed in at-risk groups, and early referral to ophthalmic services is made to prevent vision disturbances. Similarly, ophthalmologists seeing patients with any of these conditions should consider screening and referring patients for assessment of possible OSA.

Obstructive sleep apnoea and glaucoma: a systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnoea (OSA) has been thought to be associated with glaucoma, however there are many conflicting studies on this topic. With many new studies having been published since the previous meta-analysis, we believe it is important to clarify this association. Hence, in this study we meta-analyse the recent literature regarding the association between OSA and glaucoma.

METHODS

Pubmed, Embase, Scopus and Cochrane Library were searched from inception till the 28th February 2022 for observational as well as cross-sectional studies examining the association between OSA and glaucoma. Two reviewers selected studies, extracted data, graded the quality of included non-randomized studies using the Newcastle-Ottawa scale. The overall quality of evidence was assessed using GRADE. Random-effects models were used to meta-analyse the maximally covariate- adjusted associations.

RESULTS

48 studies were included in our systematic review, with 46 suitable for meta-analysis. Total study population was 4,566,984 patients. OSA was associated with a higher risk of glaucoma (OR 3.66, 95% CI 1.70 to 7.90, I2 = 98%, p < 0.01). After adjustment for various important confounders including age, gender and patient comorbidities such as hyperlipidaemia, hypertension, cardiovascular diseases and diabetes, patients with OSA had up to 40% higher odds of glaucoma. Substantial heterogeneity was eliminated through subgroup and sensitivity analyses after consideration of glaucoma subtype, OSA severity and adjustment for confounders.

CONCLUSIONS

In this meta-analysis, OSA was associated with higher risk of glaucoma, as well as more severe ocular findings characteristic of the glaucomatous disease process. We suggest more clinical studies looking into the effects of OSA treatment on the progression of glaucoma to help clinical decision making for patients.

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).

Ocular manifestations of common pulmonary diseases: a narrative review

Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.

Association between obstructive sleep apnea and floppy eyelid syndrome: A systematic review and metaanalysis

RATIONALE

Obstructive sleep apnoea (OSA) has been linked to various ocular disorders, including floppy eyelid syndrome (FES). Previous studies have hypothesised the underlying association between the 2 , but results are currently still inconclusive.

OBJECTIVE

To investigate the association between OSA and FES.

METHODS

Four databases (Pubmed, Embase, Scopus, and Cochrane Library) were searched from inception until 28 February 2022 for observational studies and randomized controlled trials assessing the association between OSA and FES. Two reviewers selected studies, extracted data, graded the risk of bias using the Newcastle-Ottawa scale and the quality of assessment using the Grading of Recommendations Assessment, Development, and Evaluation system. Random-effects models were used to metaanalyze the associations.

RESULTS

Twelve studies were included in the systematic review, of which nine were suitable for metaanalysis, with a combined cohort of 1,109 patients. Risk of bias was low to moderate. The overall analysis showed a significant positive association between OSA and FES (OR = 1.89, 95% CI = 1.27-2.83, I 2 = 44%). Further analysis revealed that the more severe the OSA was, the higher the risk of developing FES. Patients with severe OSA had the nominally highest risk of developing FES (OR = 3.06, 95% CI = 1.62-5.78, I 2 = 0%), followed by moderate OSA (OR = 2.53, 95% CI = 1.29-4.97, I 2 = 0%), and patients with mild OSA had the lowest risk (OR = 1.76, 95% CI = 0.85-3.62, I 2 = 0%).

CONCLUSION

Our metaanalysis reports a positive association between OSA and FES, with increasing severity of OSA correlating with a significantly higher risk of FES. More longitudinal studies with sufficient duration of follow-up are needed to better characterise the relationship between OSA and FES.

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.

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.

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.

Biomechanical properties of the cornea in Floppy eyelid syndrome

Background: Floppy eyelid syndrome (FES) is a frequently underdiagnosed disorder of unknown pathogenesis. FES has been associated with ocular conditions such as keratoconus. At present, despite the frequent combination of FES and keratoconus, there are almost no data on the biomechanical properties of the cornea in these patients. Aims: to determine the corneas biomechanical properties in patients with floppy eyelid syndrome. Methods: The study included 40 patients (54 eyes) with hyper-extensible eyelid syndrome. The average age was 53.96.7 years. The central corneal thickness averaged 55125 m. All the patients underwent a standard ophthalmological examination, including pneumotonometry. The intraocular pressure (IOP) and biomechanical properties of the cornea were measured using dynamic bidirectional applanation. Results: The study of the corneas biomechanical properties in patients with floppy eyelid syndrome showed a decrease in the corneal hysteresis (CH) indices to 9.960.61 mm Hg on the average, in the corneal resistance factor (CRF) to 9.540.64 mm Hg. Moreover, their value varied depending on the severity of the syndrome. The mean value of the corneal compensated IOP (IOPcc) in the entire sample was 15.51.0 mm Hg, Goldman IOP (IOPg) 15.12.0 mm Hg, pneumotonometric IOP 11.612.9 mm Hg. Regardless of the severity, the pneumotonometric IOP indices did not have statistically significant differences, while as this syndrome progressed, the IOPcc and IOPg indices showed a steady decrease in the mean values. Conclusions: It was found that, in floppy eyelid syndrome, the biomechanical parameters of the cornea were reduced. At the same time, the value of these indicators varied significantly with the severity. The largest and the smallest decrease were observed in the corneal hysteresis index and the corneal-compensated IOP, respectively.

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.

Evaluation of the Ocular Surface and Meibomian Gland in Obstructive Sleep Apnea Hypopnea Syndrome

Purpose

To assess the ocular surface and meibomian gland (MG) of patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and to explore the effects of surgery for OSAHS on the ocular surface and MG.

Methods

Based on the apnea hypopnea index (AHI), 21 patients with mild OSAHS (Group A, 5/h ≤ AHI < 15/h), 20 patients with moderate OSAHS (Group B, 15/h ≤ AHI < 30/h), 62 patients with severe OSAHS (Group C, AHI ≥ 30/h) were examined. The ocular surface and MG were evaluated using Keratograph 5M. In addition, detailed Ophthalmic examination including visual acuity, refraction, slit-lamp examination of the anterior segment, corneal fluorescein staining (CFS), ocular surface disease index (OSDI) scoring, Schirmer I test (SIT) and serum lipid measurement was performed. For OSAHS patients with dry eye syndrome (DES) who underwent uvulopalatopharyngoplasty for improving AHI, the conditions of the ocular surface and MG were compared before surgery and 3 months after surgery. Only the data of the right eyes were analyzed.

Results

There were no significantly different in the OSDI score, tear meniscus height (TMH), or loss ratio of the lower eyelid (LRLE) among these groups. The first non-invasive tear film breakup time (fNIBUT), average non-invasive tear film breakup time (avNIBUT), bulbar redness index (BRI), lipid layer grading (LLG), CFS, plugged orifices and distortion in MG, the loss ratio of upper eyelid (LRUE), and the incidence of DES, floppy eyelid syndrome (FES) and meibomian gland dysfunction (MGD) showed significant differences between Groups A and C (p = 0.015, p = 0.018, p < 0.001, p = 0.022, p = 0.036, p = 0.007, p = 0.019, p = 0.017, p = 0.045, p = 0.013, and p = 0.029, respectively). The SIT in the Group A was significantly higher than in Group B (p = 0.025) and in Group C (p < 0.001). In the correlation analyses, the fNIBUT, avNIBUT, SIT and LLG had negative correlations with the AHI (p = 0.013, p = 0.010, p = 0.003, p < 0.001, and p = 0.006, respectively). The BRI, CFS and LRUE were positively correlated with the AHI (p = 0.006, p = 0.007, and p = 0.046, respectively). Three months after surgery, there were no significant differences in the ocular surface or MG.

Conclusion

Patients with severe OSAHS have poor stability of tear film and are prone to lipid-deficient dry eye as a result of the loss of meibomian gland. By improving the AHI, the ocular surface damage of OSAHS patients cannot be reversed in a short time.

Periocular Manifestation of Obstructive Sleep Apnea as a Novel Perioperative Screening Tool

Purpose

Obstructive sleep apnea (OSA) presents perioperative challenges with increased risk for complications. Floppy eyelid syndrome (FES) is associated with OSA yet has not been addressed perioperatively. The current standard for perioperative OSA screening includes assessing patient risk factors or the STOP-BANG tool, which requires an active participant. We aimed to confirm a connection between FES and OSA in presurgical patients and develop a screening method appropriate for patients with perioperative OSA risk.

Materials and Methods

162 presurgical pre-anesthesia clinic patients were enrolled. Screening questions determined eligibility. Those who were pregnant or aged < 19 were excluded. Control group included those with a STOP-BANG score < 3. Experimental group included those with BMI > 35 and OSA diagnosis. Examiners photographed participants’ eyes with vertical and horizontal retraction while two blinded ophthalmologists used a grading scale to review grade of eyelid laxity.

Results

Differences in habitus, ASA score, and hypertension as a comorbidity were significant. Sensitivity of FES screening was 52% (CI 37–66%) and specificity was 56% (CI 46–66%) for reviewer 1. For reviewer 2, sensitivity was 48% (CI 28–69%) and specificity was 72% (CI 60–81%). Negative predictive value was 86% (CI 81–90) for reviewer 1 and 88% (CI 83–92%) for reviewer 2. Inter-rater agreement was moderate.

Conclusion

While specificity and sensitivity were lower than anticipated, negative predictive value was high. Given this strong negative predictive value, our findings indicate using eyelid retraction to screen for FES has perioperative clinical utility. These findings encourage further research addressing the connection of lid laxity/FES to OSA.

Key Points

• Aimed to investigate if a FES screening tool could identify perioperative OSA risk.

• Negative predictive value for FES with OSA was 86%.

• Observing periocular lid laxity has clinical utility; is feasible in any patient.

Graphical abstract

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 Association Between Dry Eye and Sleep Disorders: The Evidence and Possible Mechanisms

Dry eye is a disease that severely affects patients' quality of life, increasing the global burden on public health and finance. There is growing evidence that a poor lifestyle is a significant risk factor for dry eye. Along with the development of society, sleep, as a way of life, is also constantly changing. The main manifestations of sleep disorders are reduced sleep time, circadian rhythm disturbances, and sleep breathing disturbances. Sleep disorders and their secondary systemic diseases have attracted wide attention in recent years. This review mainly explored the correlation between sleep disorders and dry eye, and found that sleep-related problems and other factors potentially leading from sleep disorders could be critical factors for dry eye. These results suggest that ophthalmologists should pay attention to the sleep health problems in patients with dry eye, and we hope that this paper can provide help for future research in this field.

Alterations of Ocular Surface and Tear Film in Patients with Obstructive Sleep Apnea/Hypopnea Syndrome

PURPOSE

Obstructive sleep apnea/hypopnea syndrome (OSA) results in repeated oxygen desaturation, repeated arousals, and episodic nocturnal activation of sympathetic nervous system during sleep. Untreated OSA is strongly associated with an increase of cardio- and cerebrovascular disorders, as well as the damages of ophthalmological microstructures. However, previous literature only simply studied the association between the ophthalmic disorders and OSA. In the present study, we first investigated the alterations of ocular surface and tear film non-invasively with the innovated corneal topographer in untreated OSA patients and normal control subjects. Furthermore, we analyzed in depth whether the correlations between OSA severity and ocular surface exams exist.

PARTICIPANTS AND METHODS

Participants underwent a full-night polysomnography to determine OSA occurrence and severity. All participants subsequently received Ocular Surface Disease Index questionnaire and comprehensive ocular exams, including floppy eyelid syndrome (FES) assessment, oculus scan for tear meniscus height, non-invasive keratograph tear film breakup time (NIKBUT), and ocular surface redness, endothelial cell density, and corneal fluorescein staining.

RESULTS

One hundred eighty-one participants were prospectively enrolled in the study. FES was found in 11.5% of the normal control group and 60.0% of the severe OSA group (p=0.0005). There were significant differences in the first-NIKBUT (F-NIKBUT) (p < 0.0001), average-NIKBUT (A-NIKBUT) (p = 0.0007), and redness scores over the nasal bulbar (p = 0.032), temporal bulbar (p < 0.0001), nasal limbal (p = 0.014), and temporal limbal (p < 0.0001) areas among the four groups. F-NIKBUT and A-NIKBUT were significantly shorter in the moderate/severe OSA group (apnea/hypopnea index (AHI) ≥15) than in the normal/mild OSA group (AHI <15) (both p < 0.0001). The redness scores over the temporal bulbar (p < 0.0001) and temporal limbal (p < 0.0001) areas were also significantly different in these two OSA groups. Moreover, F-NIKBUT and A-NIKBUT negatively correlated with AHI. Nasal bulbar redness, temporal bulbar redness, nasal limbal redness, and temporal limbal redness positively correlated with AHI.

CONCLUSION

OSA patients had higher occurrence of FES. The NIKBUT was significantly shorter, and the temporal conjunctival redness scores over bulbar and limbal areas were higher in the moderate/severe OSA group than in the normal/mild OSA group. NIKBUT and conjunctival hyperemia significantly correlated with the severity of untreated OSA.

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.

Ocular Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is characterized by repetitive episodes of paused breathing during sleep, which in turn induces transient nocturnal hypoxia and hypercapnia. The high prevalence of OSA and its associated health consequences place a heavy burden on the healthcare system. In particular, the consequent episodic oxygenic desaturation/reoxygenation series and arousals from sleep in patients with OSA have the potential to trigger oxidative stress, elevated systemic inflammatory responses, and autonomic dysfunction with sympathetic activation. Given these adverse side-effects, OSA is highly correlated to many eye diseases that are common in everyday ophthalmic practices. Some of these ocular consequences are reversible, but they may permanently threaten a patient’s vision if not treated appropriately. Here, this article seeks to review the ocular consequences and potential pathophysiologic associations in patients with OSA. Understanding these OSA-related eye diseases may help clinicians provide comprehensive care to their patients.

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.

Case Report: Management of Refractory Filamentary Keratitis with N-acetylcysteine

SIGNIFICANCE

Filamentary keratitis is frequently a recurrent corneal condition characterized by the presence of filaments attached to the cornea. This condition can be challenging to manage because the clinician must treat the underlying cause and filament formation. N-acetylcysteine, a mucolytic agent, should be considered as adjunctive therapy to manage refractory cases.

PURPOSE

This case demonstrates the utility of a mucolytic agent, N-acetylcysteine, to treat and manage filamentary keratitis when conventional therapies failed to provide long-term symptomatic relief and reduction of further filament formation.

CASE REPORT

A 70-year-old man with recurrent filamentary keratitis (first occurrence 8 years prior) presented to the clinic with worsening red and painful eyes for 2 days. Prior treatment and management included artificial tears and ointments, punctal plugs, topical corticosteroids, contact lenses, and eyelid hygiene. Slit-lamp examination revealed multiple corneal filaments that were removed with forceps. He was diagnosed with recurrent filamentary keratitis secondary to dry eye disease and treated with preservative-free ophthalmic ointment, oral doxycycline, and 10% N-acetylcysteine ophthalmic solution. The patient had complete resolution of corneal filaments with significant relief of symptoms at 3-week, 5-month, and 10-month follow-up examinations.

CONCLUSIONS

N-acetylcysteine is not commercially available in an ophthalmic solution and must be compounded by a local pharmacist for patient use. Because filamentary keratitis can be challenging to manage because of frequent recurrences, addition of N-acetylcysteine to the treatment regimen should be considered a viable option in refractory cases when other therapies have failed to provide sustained symptomatic relief and resolution of filaments.

Floppy eyelid syndrome and ectropion improvement after 1 month of 0.03% Bimatoprost topical therapy

Purpose

To report the clinical improvement observed in a glaucomatous patient affected by floppy eyelid syndrome and ectropion after treatment with Bimatoprost 0.03%.

Methods

Retrospective observational case report of a single glaucomatous patient (caucasian, 82 years old) affected by floppy eyelid syndrome with marked eyelid laxity and ectropion after 1 month of once a day 0.03% Bimatoprost ocular drop administration.

Results

We observed a reduction of intraocular pressure (36% in the right eye and 37.5% in the left eye) and an unexpected improvement of eyelid laxity and inferior ectropion after 1 month of therapy with topical 0.03% Bimatoprost. Secondary outcomes were the improvement of the related ocular surface diseases and the decrease of the upper eyelid dermatochalasis. No side effect in terms of conjunctival inflammation and eyelashes growth was observed.

Conclusions and Importance

The first observational clinical case of a possible prostaglandin therapeutic effect on periocular tissue improving the laxity and malposition of the eyelids in a patient with floppy eyelid syndrome associated with inferior eyelid ectropion.

The Prevalence and Incidence of Dry Eye Disease Among Patients Using Continuous Positive Airway Pressure or Other Nasal Mask Therapy Devices to Treat Sleep Apnea

Introduction

Dry eye disease (DED) prevalence is estimated at 9.3% of the US adult population, although diagnosed rate is much lower. This study examined real-world incidence rates (IR) and prevalence rates (PR) of DED in adults using continuous positive airway pressure (CPAP) or nasal mask therapy (NMT) devices to treat sleep apnea.

Methods

Using IBM MarketScan Commercial and Medicare Supplemental claims databases, this study identified adults with ≥1 claim of CPAP or other NMT device between January 1, 2014 and June 30, 2018, ≥1 diagnosis of sleep apnea during a 12-month pre-index period, and continuous benefit enrollment ≥12 pre- and post-index date. The date of the first CPAP or NMT device claim was considered the index date. Descriptive analyses included PR, IR, and IR per 100-person years (100PY) for the overall population and subgroups including age, sex, and baseline comorbidities.

Results

The 1-, 2-, and 3-year PR of DED was 6.2%, 10.0%, and 13.0%, while the IR of DED was 4.0%, 7.3%, and 10.3%, respectively. Females had a higher IR of DED compared to males: 5.8%, 10.8%, and 15.1% vs 3.0%, 5.4%, and 7.9%, respectively. DED increased with age with a 1-, 2-, and 3-year PR for patients aged 18–24 years of 2.2%, 3.4%, and 5.0% vs 17.6%, 25.8%, and 32.1% in patients aged ≥75, respectively. Overall, IR per 100PY of DED was 3.68, higher for females than males (5.51 vs 2.73). PR and IR of DED were high among patients with comorbid inflammatory or metabolic conditions.

Conclusion

The PR and IR of DED in CPAP or NMT users were higher than the reported prevalence of DED in the general population. CPAP/NMT users who were female, older, or had comorbid inflammatory or metabolic conditions may experience a higher incidence and prevalence of DED.

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.

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.

Long-term Effect of Continuous Positive Air Pressure Therapy on Intraocular Pressure in Patients with Primary Open-angle Glaucoma with Obstructive Sleep Apnea

PURPOSE

Prevalence of glaucoma is higher in obstructive sleep apnea (OSA) patients. The gold standard technique to treat OSA is continuous positive airway pressure (CPAP) therapy. The influence of long-term CPAP therapy on intraocular pressure (IOP), blood pressure, ocular perfusion pressure (OPP), and glaucoma progression in primary open-angle glaucoma (POAG) patients was evaluated.

DESIGN

Prospective study.

MATERIALS AND METHODS

In this study, we enrolled 12 eyes from six POAG patients aged >35 years, with newly diagnosed OSA and with indication for CPAP therapy. The CPAP was performed for 12 months. We monitored the IOP every 3 months. Visual field was determined at baseline and 12 months.

RESULTS

The mean IOP after CPAP therapy for 12 months was significantly higher than the mean baseline IOP (average IOP 3 months before CPAP therapy) (19.08 ± 3.47 vs 17.83 ± 2.88 mm Hg; p = 0.006). The IOP rising rate was 0.69 ± 0.47/years (p = 0.138) before CPAP therapy and increased to 1.13 ± 0.47/years (p = 0.016) after CPAP therapy. The OPP after 12 months of CPAP was significantly lower than the baseline (42.21 ± 5.29 vs 45.24 ± 7.09 mm Hg; p = 0.06). Results showed that the pattern standard deviation (PSD) value of 24-2 short wavelength automated perimetry (SWAP) visual field was reduced from 5.34 ± 3.92 to 4.77 ± 3.73 (p = 0.025). Antiglaucoma medication was administered to a patient due to increased IOP without glaucoma progression evidence.

CONCLUSION

The POAG and OSA patients demonstrated significant IOP rising after CPAP therapy but did not show progression of glaucomatous damage. Mean deviation (MD), PSD, and visual field index (VFI) were not significantly different after CPAP therapy.

PRÉCIS

Prospective study of POAG and OSA patients demonstrated significant IOP rising after CPAP therapy for a year. The study did not show progression of glaucomatous damage.

HOW TO CITE THIS ARTICLE

Hirunpatravong P, Kasemsup T, Ayudhya WN, et al. Long-term Effect of Continuous Positive Air Pressure Therapy on Intraocular Pressure in Patients with Primary Open-angle Glaucoma with Obstructive Sleep Apnea. J Curr Glaucoma Pract 2019;13(3):94-98.

Prevalence and Predictors of Ocular Complications in Obstructive Sleep Apnea Patients: A Cross-sectional Case-control Study

Purpose:

This study sought to identify the magnitude and the possible risk factors of ocular complications in patients with Obstructive Sleep Apnea (OSA).

Methods:

A hospital-based cross-sectional study with a nested case-control design was conducted. Qualifying study subjects were patients who had been diagnosed with moderate to severe OSA (AHI index of ≥ 5, n=80), and control subjects (n=20) who had an AHI index of ≤ 5 (“normal”). Study participants were recruited from Mansoura University Hospital’s Sleep Disorders Clinic in Mansoura, Egypt.Selected subjects were assessed for ocular complications at Mansoura Univerity Hospital Ophthalmic Center, (Mansoura), Egypt. An ophthalmic history was recorded, and opthalmic testing was carried out. The testing included unaided visual acuity measurement, refraction, best-corrected visual acuity measurement, slit lamp bio-microscopic evaluation of the anterior segment and anterior segment photography, dilated fundus examination, intraocular pressure measurement, fundus photo, and fluorescein angiography, and visual field assessment. Various tests of OSA symptoms were also monitored, including the AHI, lowest oxygen concentrations and desaturation index plus the overall severity index. .

Results:

It was found that OSA patients n=28 (35%), n=24 (30%), n=4 (5%) had senile cataract, normal tension glaucoma, and retinal ischemia, respectively, with an overall prevalence of 45%. Additionally, the OSA group had seven times greater risk (OR=7.36, 95%CI: 1.6-33.86) of vision-threatening disorders compared to the controls. OSA patients were observed to be at a greater risk of senile cataract 28 (35%), normal tension glaucoma 24 (30%), retinal ischemia 4 (5%) and conjunctival hyperemia and dry eye (OR=3.77, 95%CI: 1.02-13.95, OR=4.36, 95%CI: 1.26-17.08). Also, multivariate logistic regression analysis testing showed that the lowest oxygen saturation index was the only significant predictor negatively associated with vision-threatening disorders (OR=0.84, 95%CI: 0.75-0.93).

Conclusion:

The risk of vision-threatening and non-threatening ocular disorders is higher among OSA cases. The lowest oxygen saturation index was the only significant predictor of vision-threatening disorders. These findings support the recommendation that a full ophthalmic examination should be carried out on patients with confirmed OSA.

Ocular surface assessment and morphological alterations in meibomian glands with meibography in obstructive sleep apnea Syndrome

PURPOSE

To evaluate ocular surface and Meibomian glands morphology of patients with obstructive sleep apnea syndrome (OSAS).

MATERIALS AND METHODS

Based on polysomnography, 36 eyes of 36 patients with severe OSAS (Group 1, apnea-hypopnea index (AHI) ≥30/h) and 24 eyes of 24 patients with primary snoring or mild OSAS (Group 2, AHI<15/h) were enrolled. Detailed eye examination along with ocular surface staining (fluorescein, 2%) according to Oxford scale, tear film break-up time (t-BUT), Schirmer 1 test, ocular surface disease index (OSDI) scoring, and evaluation of upper and lower eyelid Meibomian glands using infrared filter of slit-lamp biomicroscope were performed. In addition to grading Meibomian gland drop-out, the presence morphologic alterations such as Meibomian gland duct distortion, thinning and dilatation were also assessed.

RESULTS

The mean ages were 50.8 ± 8.3 (range, 35-68) and 47.9 ± 10.5 (range, 27-69) in Group 1 and Group 2, respectively (p = 0.616). Best-corrected visual acuity, Schirmer 1 test, Oxford scale and OSDI scores, and lower meiboscores did not differ significantly between groups. In Group 1, average t-BUT was lower (p = 0.003), upper and total (upper + lower) meiboscores were higher as compared to Group 2 (p < 0.05). The frequency of Meibomian gland duct distortion, thinning and dilatation were also significantly greater in Group 1 (p < 0.05).

CONCLUSION

Morphological changes, in addition to Meibomian glands dropout were significant in severe OSAS patients as demonstrated objectively with meibography. Schirmer 1 and t-BUT tests were in favor of evaporative type dry eye syndrome, which also support Meibomian gland alterations in severe OSAS patients.

Late-onset bleb-associated endophthalmitis and continuous positive airway pressure

PURPOSE

To raise awareness of a possible association between continuous positive airway pressure (CPAP) devices and postoperative bleb-related infection.

OBSERVATIONS

A 57-year old patient on CPAP presented with unilateral bleb-associated endophthalmitis 32 months after routine ExPress Trabeculectomy with mitomycin C. The offending organism, Streptococcus mitis, is a nonmotile and generally non-virulent pathogen which predominates in the normal human respiratory flora.

CONCLUSIONS AND IMPORTANCE

This conceptual report underscores a potential relationship between CPAP use and bleb-associated endophthalmitis. Streptococcal species are the most commonly reported causative organisms in bleb-associated endophthalmitis, and S. mitis is of particular concern as the most abundant microbe among all human oral flora. A logical risk factor for infection, the CPAP device may inadvertently deliver such organisms to the vulnerable conjunctival filtering bleb.

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.

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.

Association Between Eyelid Laxity and Obstructive Sleep Apnea

Importance

While much has been reported on the relationship between floppy eyelid syndrome and obstructive sleep apnea (OSA), the diagnostic criteria of floppy eyelid syndrome are often subjective and vague.

Objective

To evaluate the association between OSA and quantitative markers of eyelid laxity or secondary ocular surface disease in a sleep clinic population.

Design, Setting, and Participants

This investigation was a cross-sectional observational study at the Center for Sleep Medicine at Icahn School of Medicine at Mount Sinai. Participants were individuals referred for overnight polysomnography from March 1 to August 30, 2015.

Main Outcomes and Measures

Eyelid laxity and ocular surface disease were assessed on bedside ophthalmologic examination. The presence and severity of OSA were determined from polysomnography results. Initial correlation between OSA and ocular surface and eyelid markers was calculated through bivariate linear regression analysis, and the association between ocular symptoms was obtained through bivariate ordered logistic regression. Analysis was repeated adjusting for known associations between OSA and sex, age, body mass index, and medical comorbidities through multivariable analysis.

Results

In total, 201 individuals (402 eyes) were enrolled in the study. Their mean (SD) age was 53.2 (13.5) years, 43.3% (n = 87) were female, 56.7% (n = 114) were of white race/ethnicity, 26.9% (n = 54) were black/African American, 4.0% (n = 8) were Asian, 8.0% (n = 16) were multiracial or other, and 4.5% (n = 9) were of unknown race/ethnicity, with 21.9% (n = 44) of all individuals self-identifying as Hispanic and 75.1% (n = 151) self-identifying as non-Hispanic. After adjustment, no association was observed between OSA severity and an eyelid laxity score (regression coefficient, 0.85; 95% CI, -0.33 to 0.62; P = .40) or an ocular surface score (regression coefficient, 1.09; 95% CI, -0.32 to 0.29; P = .93). Through subset analysis, male sex was associated with a higher ocular surface score, while older age and diabetes were associated with a higher eyelid laxity score. Only one patient (0.5%) exhibited findings of floppy eyelid syndrome.

Conclusions and Relevance

Among individuals referred for overnight polysomnography, quantitative markers of eyelid laxity were not associated with the presence or severity of OSA. Subset analysis suggests that prior studies may have been limited by confounding variables or the technique of identifying eyelid laxity.

Prevalence and risk factors of eye diseases in adult patients with obstructive sleep apnoea: results from the SLE.E.P.Y cohort study

OBJECTIVES

To assess the occurrence of glaucoma, eyelid, corneal and macular disorders in a cohort of patients with obstructive sleep apnoea (OSA) diagnosed by overnight polysomnography and to investigate into the risk factors for the above eye diseases (EDs).

DESIGN

Cross-sectional cohort study between 2014 and 2015.

SETTING

Unit of Respiratory Medicine and Eye Clinic of the University of Verona.

PARTICIPANTS

431 consecutive patients were considered eligible. Of these, 87 declined to participate, 35 were untraceable and 13 were deceased.

INTERVENTIONS

A complete ophthalmic evaluation of both eyes for each patient.

PRIMARY AND SECONDARY OUTCOME MEASURES

Best-corrected distance visual acuity, intraocular pressure, corneal, macular and optic nerve optical coherence tomography, ocular aberrometry, optic nerve laser polarimetry, visual field test, and eyelid examination.

RESULTS

296 patients aged 64.5±12.8 years, 23% female and 77% male, underwent ophthalmic examination. There was 56% (n=166) prevalence of eyelid disorders, 27% (n=80) of corneal disorders, 13% (n=39) of macular disorders and 11% (n=33) of glaucoma. Advancing age was not associated with the severity of OSA, while significant differences were found for gender, body mass index, Oxygen Desaturation Index, smoking habit, hypertension and diabetes. Severe OSA was significantly associated with glaucoma (OR, 95% CI 1.05 to 5.93, p=0.037).

CONCLUSIONS

EDs were more prevalent in our patinets with OSA than in the general population. Severe Apnoea/Hypopnoea Index level seemed to play a role as risk factor only for glaucoma.

Corneal Neovascularization with Associated Lipid Keratopathy in a Patient with Obstructive Sleep Apnea-Hypopnea Syndrome Using a Continuous Positive Airway Pressure Machine

Objective

To report a case of corneal neovascularization with secondary lipid keratopathy in a patient treated with continuous positive airway pressure (CPAP) for obstructive sleep apnea-hypopnea syndrome (OSAHS).

Case Report

A 49-year-old male had been diagnosed with obstructive sleep apnea syndrome 10 years ago and has been treated with the application of a CPAP machine during night sleep ever since. For the past year, the patient had been complaining for ocular irritation and excessive tearing of the left eye on awakening. Slit-lamp biomicroscopy revealed the presence of neovascularization and lipid exudation in the inferior third of the cornea of the left eye. Ocular patching during night sleep resulted in recession of the reported symptoms and shrinkage of the neovascularization, while the area of lipid exudation ceased to enlarge.

Conclusion

To the best of our knowledge, this is the first report of corneal neovascularization in a patient using a CPAP machine for OSAHS.

Repercusiones oftalmológicas del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

Las manifestaciones oftalmológicas que se relacionan con el síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) incluyen síndrome de párpado flácido y cambios a nivel del nervio óptico asociados con glaucoma, así como neuropatía óptica isquémica anterior no arterítica y papiledema. La prevalencia del síndrome de párpado flácido en pacientes con SAHOS varía entre 2.3% y 32.6%, mientras que de la asociación entre glaucoma y SAHOS oscila entre 2% y 27%.En la población estudiada en Colombia se encuentra una frecuencia de 2.7% de asociación entre glaucoma de presión normal y SAHOS. El glaucoma presente en estos casos es el primario de ángulo abierto, que bien puede cursar con o sin un aumento de la presión intraocular. En cuanto a la neuropatía óptica isquémica y el papiledema, no se dispone de datos acerca de su prevalencia en pacientes con SAHOS. Se recomienda la valoración por oftalmología a los pacientes diagnosticados con este síndrome.

Gel pillow designed specifically for obstructive sleep apnea treatment with continuous positive airway pressure

Objective:

To determine whether the use of a gel pillow with side cutouts designed to accommodate a continuous positive airway pressure (CPAP) mask and reduce head temperature improves the efficacy of and adherence to auto-CPAP therapy.

Methods:

Twenty-three consecutive CPAP-naïve patients with obstructive sleep apnea were enrolled in the study. Patients were given an auto-CPAP machine with an appropriate CPAP mask and were instructed to use CPAP for 15 nights. They were instructed to sleep with their own pillow (the control pillow) from nights 1 to 5 and with either a foam pillow or a gel pillow, both of which had side cutouts, for 5 consecutive nights each, in random order. After night 15, auto-CPAP machine data were downloaded and patients rated their satisfaction with each pillow on a visual analog scale.

Results:

Twenty-two patients completed the protocol. The pressures administered, residual apnea-hypopnea index, air leaks, and mean duration of CPAP use did not differ among the periods during which each pillow was used. Patients were significantly more satisfied with the gel pillow than with the control pillow and the foam pillow (p = 0.022 and p = 0.004, respectively), their level of satisfaction with the gel pillow correlating significantly with excessive daytime sleepiness (r² = 0.19; p = 0.0443).

Conclusions:

Among obstructive sleep apnea patients treated with nasal CPAP, the use of a gel pillow with side cutouts appears to have no impact on treatment effectiveness. Nevertheless, such patients seem to prefer a gel pillow over other types of pillows.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.

Treatment of Obstructive Sleep Apnea. Prospects for Personalized Combined Modality Therapy

Obstructive sleep apnea (OSA) is a common sleep disorder with serious associated morbidities. Although several treatment options are currently available, variable efficacy and adherence result in many patients either not being treated or receiving inadequate treatment long term. Personalized treatment based on relevant patient characteristics may improve adherence to treatment and long-term clinical outcomes. Four key traits of upper airway anatomy and neuromuscular control interact to varying degrees within individuals to cause OSA. These are: (1) the pharyngeal critical closing pressure, (2) the stability of ventilator chemoreflex feedback control (loop gain), (3) the negative intraesophageal pressure that triggers arousal (arousal threshold), and (4) the level of stimulus required to activated upper airway dilator muscles (upper airway recruitment threshold). Simplified diagnostic methods are being developed to assess these pathophysiological traits, potentially allowing prediction of which treatment would best suit each patient. In contrast to current practice of using various treatment modes alone, model predictions and pilot clinical trials show improved outcomes by combining several treatments targeted to each patient's pathophysiology profile. These developments could theoretically improve efficacy and adherence to treatment and in turn reduce the social and economic health burden of OSA and the associated life-threatening morbidities. This article reviews OSA pathophysiology and identifies currently available and investigational treatments that may be combined in the future to optimize therapy based on individual profiles of key patient pathophysiological traits.

Is Floppy Eyelid Syndrome More Prevalent in Obstructive Sleep Apnea Syndrome Patients?

Controversial findings are reported about the relationship between floppy eyelid syndrome (FES) and obstructive sleep apnea syndrome (OSAS). The main goal of this study was to evaluate whether FES is more prevalent in OSAS patients by performing a meta-analysis. A comprehensive literature search of Pubmed, Embase, and Cochrane databases was performed. Only studies related to the prevalence of FES in OSAS were included in the meta-analysis. We estimated a pooled odds ratio (OR) for the prevalence of FES in OSAS. In total, 6 studies with 767 participants met the inclusion criteria. Using a fixed-effects model, the pooled OR was 4.12. The test for the overall effect revealed that FES was statistically prevalent in OSAS patients when compared with that in non-OSAS subjects (Z = 4.98, p < 0.00001). In the subgroup analysis by OSAS severity, the incidence of FES in OSAS increased with severity of OSAS as indicated with increased OR values (OR = 2.56, 4.62, and 7.64 for mild, moderate, and severe OSAS). In conclusion, the results indicate that FES is more prevalent in OSAS patients. However, this result was based only on unadjusted estimates. Prospective cohort studies are needed to determine whether OSAS is an independent risk factor for FES.

The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to evaluate the association between obstructive sleep apnea (OSA) and ophthalmologic diseases, specifically glaucoma, nonarteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), central serous chorioretinopathy (CSR), and floppy eyelid syndrome (FES), by performing a systematic review and meta-analysis of published studies.

METHODS

PubMed, Embase, and Scopus databases were searched for observational studies on OSA and its association with select ophthalmologic diseases. Data was pooled for random-effects modeling. The association between OSA and ophthalmologic diseases was summarized using an estimated pooled odds ratio with a 95 % confidence interval.

RESULTS

Relative to non-OSA subjects, OSA subjects have increased odds of diagnosis with glaucoma (pooled odds ratio (OR) = 1.242; P < 0.001) and floppy eyelids syndrome (pooled OR = 4.157; P < 0.001). In reverse, the overall pooled OR for OSA was 1.746 (P = 0.002) in the glaucoma group, 3.126 (P = 0.000) in the NAION group, and 2.019 (P = 0.028) in the CSR group. For RVO, one study with 5965 OSA patients and 29,669 controls demonstrated a 1.94-fold odds increase in OSA patients.

CONCLUSIONS

Our results suggest significant associations between OSA and glaucoma, NAION, CSR, and FES. Screening for OSA should be considered in patients with glaucoma, NAION, CSR, or FES.

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.