Obstructive sleep apnea and central serous chorioretinopathy

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.

Retinal abnormalities, although relatively common in sleep clinic patients referred for polysomnography, are largely unrelated to sleep-disordered breathing

Study objectives.

There has been long-standing interest in potential links between obstructive sleep apnea (OSA) and eye disease. This study used retinal photography to identify undiagnosed retinal abnormalities in a cohort of sleep clinic patients referred for polysomnography (PSG) and then determined associations with PSG-quantified sleep-disordered breathing (SDB) severity.

Methods

Retinal photographs (n = 396 patients) were taken of each eye prior to polysomnography and graded according to validated, standardized, grading scales. SDB was quantified via in-laboratory polysomnography (PSG; n = 385) using standard metrics. A questionnaire (n = 259) documented patient-identified pre-existing eye disease. Within-group prevalence rates were calculated on a per patient basis. Data were analyzed using multivariate logistic regression models to determine independent predictors for retinal abnormalities. P < 0.05 was considered significant.

Results

Main findings were (1) 76% of patients reported no pre-existing “eye problems”; (2) however, 93% of patients had at least one undiagnosed retinal photograph-identified abnormality; (3) most common abnormalities were drusen (72%) and peripapillary atrophy (PPA; 47%); (4) age was the most common risk factor; (5) diabetes history was an expected risk factor for retinopathy; (6) patients with very severe levels of SDB (apnea hypopnea index ≥ 50 events/h) were nearly three times more likely to have PPA.

Conclusion

Retinal photography in sleep clinic settings will likely detect a range of undiagnosed retinal abnormalities, most related to patient demographics and comorbidities and, except for PPA, not associated with SDB. PPA may be indicative of glaucoma, and any association with severe SDB should be confirmed in larger prospective studies.

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 ASSOCIATION BETWEEN CENTRAL SEROUS CHORIORETINOPATHY AND SLEEP APNEA: A Nationwide Population-Based Study

PURPOSE

To identify the association between sleep apnea (SA) and central serous chorioretinopathy (CSC).

METHODS

In this nationwide population-based study using the Taiwan National Health Insurance Database, we enrolled adult patients with a diagnosis of SA and matched each patient to 30 age- and gender-matched control subjects without any SA diagnosis. Using Poisson regression analyses, the incidence rate of CSC was compared between SA patients and control subjects.

RESULTS

A total of 10,753 SA patients and 322,590 control subjects were identified. After adjusting for age, gender, residency, income level, and comorbidities, the incidence rate of CSC was significantly higher in SA patients than in the control subjects (adjusted incident rate ratio for probable SA: 1.2 [95% CI: 1.1-1.4], P < 0.0001). Analyses of the propensity score-matched subpopulations also confirmed our findings. Risk factors for CSC in SA patients included male gender, age ≤50 years, higher income, presence of heart disease, absence of chronic pulmonary disease, and presence of liver disease. In SA patients, those who had received continuous positive airway pressure titration had a significantly lower incidence rate of CSC than the others.

CONCLUSION

Our study revealed a significantly higher incidence rate of CSC in SA patients compared with the control subjects.

Obstructive sleep apnea and the retina: a review

CITATION

This review's objective was to synthesize the literature on the repercussions of obstructive sleep apnea (OSA) in the retinal vascular system. Two independent investigators conducted a search using the MEDLINE/PubMed database using the following terms: sleep apnea syndrome, obstructive sleep apnea, retina, vascular tortuosity, central serous chorioretinopathy, diabetes mellitus, and subfoveal choroidal thickness. Patients with OSA present increased vascular tortuosity compared with patients without OSA, decreased parafoveal and peripapillary vessel density, and increased retinal vein occlusion incidence. In central serous chorioretinopathy patients and patients who are poor responders to intravitreal anti-VEGF (-vascular endothelial growth factor) treatment for macular edema, OSA is more frequent. Macular choroidal thickness alterations are controversial, and OSA may worsen diabetic maculopathy, thus being a risk factor for diabetic retinopathy, proliferative diabetic retinopathy, and macular edema. OSA is a prevalent syndrome with many systemic vascular changes. The retina and choroid are the most affected ocular structures, with primarily vascular changes. New noninvasive technologies such as optical coherence tomography and optical coherence tomography angiography could help to better understand retinal structures and help clarify the ophthalmological repercussions of OSA.

CITATION

Nakayama LF, Tempaku PF, Bergamo VC, et al. Obstructive sleep apnea and the retina: a review. J Clin Sleep Med. 2021;17(9):1947-1952.

Association of Retinal Vascular Manifestation and Obstructive Sleep Apnea (OSA): A Narrative Review

Obstructive sleep apnea (OSA) is characterized by frequent episodes of partial or complete obstruction of the airway during sleep causing repeated episodes of apnea. OSA is more prevalent in middle-aged and older adults. OSA is associated with numerous ocular manifestations, including retinal manifestations. Literature highlighted the clear association between OSA and numerous ocular conditions including glaucoma and papilledema. This comprehensive and narrative review aims to summarize up-to-date clinical research concerning the association of OSA and vascular conditions that affect the retina. OSA is associated with the central serous chorioretinopathy (CSC), retinal vein occlusion (RVO), hypertensive retinopathy (HTRP) and development of diabetic retinopathy (DR). Sympathetic activation, hypoxia, and hormonal dysregulation all lead to serious retinal vascular conditions that will worsen OSA patients’ quality of life. It is important to refer patients with newly diagnosed OSA to an ophthalmology clinic for the appropriate test.

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.

Relationship between Obstructive Sleep Apnea and Central Serous Chorioretinopathy: A Health Insurance Database Study

Purpose: To evaluate the association between obstructive sleep apnea (OSA) and central serous chorioretinopathy (CSCR).Methods: A retrospective, cohort, longitudinal study was conducted using the national health insurance database in Taiwan between 1996 and 2013. Patients diagnosed with OSA were enrolled after exclusion, and a control group with similar age, gender, and major systemic co-morbidities were included in a 1:1 ratio by propensity score matching. The primary outcome is the occurrence of CSCR, and patients with CSCR were categorized via severity for further analysis. The percentage of incident CSCR in the OSA group and control groups and the adjusted hazard ratios (aHR) of CSCR were determined by Cox proportional hazard regression.Results: There were 13,084 patients enrolled in both the OSA group and control groups, respectively. The total event of CSCR was 50 (0.4%) in the OSA group and 25 (0.2%) in the control group (P < .001). Moreover, the OSA group has an increased aHR of 1.9 (P = .012) for developing CSCR. In the subgroup analysis, patients with OSA aged from 30 to 39 and 50 to 59 demonstrated higher risk of developing CSCR compared to the control group, and the presence of OSA would lead to a higher incidence of mild CSCR (all P < .05).Conclusions: OSA patients aged from 30 to 39 and 50 to 59 have a higher risk of developing CSCR, while the severity of CSCR will not be worsen by OSA.

Plasma dopamine and catecholamine levels in patients with central serous chorioretinopathy

PURPOSE

To evaluate plasma dopamine and catecholamine levels in patients with central serous chorioretinopathy (CSCR).

MATERIALS AND METHODS

In this prospective study, 32 patients with acute CSCR were included, along with 32 age- and gender-matched healthy controls without CSCR. Complete ophthalmologic examinations were performed. Plasma dopamine, epinephrine, norepinephrine levels were measured in the morning after 8-12hours of fasting. A P-value of less than 0.05 was considered statistically significant.

RESULTS

While the mean age of the CSCR group was 40.12±7.96 years, the mean age of the control group was 37.81±7.26 years. There was no statistically significant difference between the groups in terms of age or gender (P=0.229, P=0.740, respectively). The plasma dopamine level was 29.85±9.39pg/ml in the CSCR group and 23.93±7.33pg/ml in the control group (P=0.001). The plasma epinephrine level was 60.73±25.69pg/ml in the CSCR group and 45.77±18.55pg/ml in the control group (P=0.021). The plasma norepinephrine level was 206.68±71.51pg/ml in the CSCR group and 149.33±49.69pg/ml in the control group (P=0.001). Plasma dopamine, epinephrine, and norepinephrine levels were statistically significantly higher in the CSCR group.

CONCLUSION

We concluded that dopamine may be a possible factor in the etiology of CSCR, both through its receptors and by enhancing sympathetic activity.

Exploring the Biopsychosocial Pathways Shared by Obstructive Sleep Apnea (OSA) and Central Serous Chorioretinopathy (CSC): A Literature Overview

This study addressed the following question: “Is it possible to highlight the link between obstructive sleep apnea (OSA) and central serous chorioretinopathy (CSC) through common biopsychosocial pathogenetic pathways?”. The study was conducted through electronic searches of the PubMed, Web of Science, and Scopus databases. All relevant selected human research studies published from January 2003 to December 2020 were included. The scientific literature search was performed through repeated use of the words “OSA” and/or “acute/chronic CSC” paired with “biomedical/biopsychosocial illness model”, “psychopathology”, “stress”, “personality characteristics”, “functional diseases”, “comorbidity”, and “quality of life” in different combinations. Our literature search identified 213 reports, of which 54 articles were ultimately reviewed in this paper. Taken together, the results indicate that there is a cross-link between OSA and CSC that can be classified among biopsychological disorders in which various major biological variables integrate with psychological-functional and sociological variables; many of these variables appear in both diseases. This concept can have important implications for improving patients’ quality of life, thus providing the necessary strategies to cope with challenging life events even through nonpharmacological approaches.

Personality Traits, Stress, and Emotional Intelligence Associated with Central Serous Chorioretinopathy

BACKGROUND The aim of the present study was to investigate the relationship between personality traits, stress, emotional intelligence, and central serous chorioretinopathy (CSCR). MATERIAL AND METHODS This prospective case-control study included 57 patients with acute CSCR and 57 age- and sex-matched controls with refractive errors. Inclusion criteria for CSCR group were acute unilateral onset of visual disturbances within 2 weeks until the first visit to the ophthalmologist and ophthalmoscopic finding of a round or oval macular detachment confirmed by optical coherence tomography as a dome-shaped serous neuroretinal elevation. RESULTS Using the Sixteen Personality Factor Questionnaire (16 PF), patients with CSCR achieved slightly higher scores on primary characteristics such as warmth (P=0.612) and perfectionism (P=0.137) when compared to the control subjects. Mean scores measured with the Social Readjustment Rating Scale (SRRS) were significantly higher in patients with CSCR (P=0.004), which means that these patients had notably elevated average reactivity to stressful life events. In addition, the number of patients with a high stress level was higher in the CSCR group than in the control group. Considering the level of emotional intelligence measured with the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF), patients with CSCR achieved significantly lower scores on well-being (P=0.003) and sociability (P=0.011) factors, as well as on total score (P=0.014). CONCLUSIONS A higher level of perceived stress is the most important psychological risk factor for CSCR. According to our results, a low level of emotional intelligence may be an additional factor that contributes to the occurrence of CSCR.

Plasma cerebellin levels in patients with central serous chorioretinopathy

PURPOSE

To evaluate levels of plasma cerebellin, cortisol, adrenaline and noradrenaline in patients with central serous chorioretinopathy (CSC).

MATERIALS AND METHODS

This prospective study included 30 patients diagnosed with acute CSC (Group 1) and a control group of 30 age-matched, healthy subjects without CSC (Group 2). Levels of plasma cerebellin, cortisol, adrenaline and noradrenaline were examined in blood samples taken after 8-12hours of fasting. A value of p<0.05 was considered statistically significant in the comparative analyses.

RESULTS

The mean plasma cerebellin level was found to be 232.56±113.28 pg/ml in Group 1 and 174.07±82.04 pg/ml in Group 2 (p=0.02). Mean plasma cortisol was 13.19±3.87μg/ml in Group 1 and 9.55±2.92μg/ml in Group 2 (p<0.01). Mean plasma adrenaline was 60.62±26.67 pg/ml in Group 1 and 46.17±19.20 pg/ml in Group 2 (p=0.03). Mean plasma noradrenaline was 206.66±73.90 pg/ml in Group 1 and 149.96±51.36 pg/ml in Group 2 (p<0.01).

CONCLUSION

It can be concluded that increased cerebellin may have a role in the etiology of CSC by increasing catecholamine expression from the adrenal medulla and indirectly by increasing cortisol levels via a paracrine effect from the adrenal cortex.

The Effect of Obstructive Sleep Apnea on Absolute Risk of Central Serous Chorioretinopathy

PURPOSE

To determine the incidence of central serous chorioretinopathy (CSC) stratified by age, sex, and diagnosis with obstructive sleep apnea (OSA), and to determine whether some patients with newly diagnosed CSC may be candidates for OSA evaluation.

DESIGN

Retrospective cohort study.

METHODS

We used the IBM MarketScan database to select 59,016,145 commercially insured patients in the United States between 2007 and 2016. We identified patients' first diagnosis with CSC, and defined patients as having OSA if they had a diagnosis following a sleep study. We specified Cox proportional hazard models with interactions between age, sex, and OSA status to determine patients' risk of developing CSC. We estimated the positive predictive value (PPV) that a new diagnosis of CSC would have in predicting a subsequent diagnosis of OSA.

RESULTS

Risk of CSC increased with age in years (hazard ratio [HR] = 1.030, P < .001) and OSA diagnosis (HR = 1.081, P < .033), and was lower in women (HR = 0.284, P < .001). We estimated the annual incidence of CSC was 9.6 and 23.4 per 100,000 women and men, respectively. Incidence was higher in women and men with OSA (17.2 and 40.8 per 100,000). The PPV of CSC diagnosis as a predictor of OSA was highest in the fifth decade of life.

CONCLUSION

The incidence of CSC in our patient sample is higher than previously reported. Risk of CSC is higher in men than in women, and OSA increases risk of CSC in both men and women. Some patients, particularly older male patients, may be good candidates for OSA evaluation following a CSC diagnosis.

Increased Risk of Central Serous Chorioretinopathy among Patients with Nonorganic Sleep Disturbance

Purpose

Patients with central serous chorioretinopathy (CSC) typically present with acute visual impairment and metamorphopsia. The disease previously has been associated with psychological stress. Population-based cohort studies on the risk of CSC among patients with nonorganic sleep disturbance (NOSD) are limited. An early sign of psychiatric disorder was probably sleep disturbance. Furthermore, psychological stress may be caused by sleep disturbance. We investigated the relationship between NOSD and the incidence of CSC.

Design

Longitudinal cohort study. Participants. We used the Longitudinal Health Insurance Database and collected the data of 53,743 NOSD patients without CSC between 2000 and 2005 as the study group. Four-fold controls were selected randomly from those without neither sleep disturbance nor a CSC history with frequency matching of age, sex, and index-year.

Methods

The difference in sex, age group, comorbidities, and steroid use between the two groups was analyzed by the χ ² test. Cox-proportional hazard regression was utilized to estimate the hazard ratio (HR) and 95% confidence intervals (95% CI) for comparison of the two groups. Kaplan-Meier analysis was applied to measure the cumulative incidence of CSC. Furthermore, the log-rank test was used to test the incidence difference between the two groups. Main Outcome Measures. The incidence rate of CSC in the following years until 2011 was detected.

Results

During a mean follow-up of 7.36 ± 2.88 years, NOSD patients had a higher incidence of CSC than the controls (3.10 vs. 1.86 per 10,000 person-years; adjusted HR, 1.65; 95% CI, 1.34-2.02). Men had a higher risk of CSC than women. Sensitivity analyses stratified by sex, age group, or comorbidity condition showed consistently that NOSD patients had a higher risk of CSC than their controls. Dose-response showed that higher NOSD severity had even higher CSC risk.

Conclusions

NOSD is an independent indicator for the increased risk of subsequent CSC development.

Correlation between structural progression in glaucoma and obstructive sleep apnea

BACKGROUND/OBJECTIVES

To investigate the correlation between obstructive sleep apnea (OSA) severity and the structural and functional progression in patients with glaucoma.

SUBJECTS/METHODS

This retrospective comparative cohort study included subjects from the polysomnography database in Chang Gung Memorial Hospital between June 1, 2009, and June 1, 2017, by identifying patients who had received diagnoses of primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), or glaucoma suspect. Patients with follow-up time of <3 years and/or <3 consecutive reliable optical coherence tomography (OCT) or visual field (VF) tests were excluded. Progression of overall peripapillary retinal nerve fiber layer (RNFL) thickness on OCT scans and VF mean deviation (MD) or VF index (VFI) were determined through linear regression trend analysis.

RESULTS

Thirty-two patients were included. There was a trend to higher percentage of progression on RNFL thickness and VF in higher OSAS severity. After stratifying patients to no OSA/mild OSA (group 1) and moderate/severe OSA (group 2), group 2 exhibited a significantly higher percentage of RNFL thickness progression than did group 1 (64.7% vs 26.7%, P = 0.042). Multivariate Cox regression analysis showed that severe OSA had an 8.448-fold higher risk of RNFL thickness progression after age, sex, diabetes mellitus, hypertension, hyperlipidemia, and body mass index adjustment (95% confidence interval, 1.464-48.752, P = 0.017).

CONCLUSIONS

Severe OSA is significantly correlated with a higher risk of structural deterioration in patients with glaucoma.

Non-resolving, recurrent and chronic central serous chorioretinopathy: available treatment options

Central serous chorioretinopathy is one of the most frequent causes of vision reduction among middle-aged men. This disease usually has a self-limiting course, but sometimes it lasts more than 4-6 months or a second episode follows a complete resolution of the first one. Nevertheless, to date no consensus exists about the duration threshold and therapy protocols for these non-resolving central serous chorioretinopathy. Treatment as half-dose and half-fluence photodynamic therapy, subthreshold micropulse laser treatment, mineralocorticoid receptor antagonists, intravitreal anti-angiogenic drugs, transpupillary thermal therapy, anti-androgenic drugs, methotrexate, Rifampicin and melatonin are described in this review. Complications are very uncommon but end-point results like central macular thickness reduction and best-corrected visual acuity improvement are difficult to compare among different therapeutic modalities due to different duration of follow-up and lack of homogeneity in patient recruitment. The aim of this review is focusing on treatment modalities for these chronic forms with comprehensive recent management updates according to latest clinical trial results.

ASSOCIATION OF OBSTRUCTIVE SLEEP APNEA WITH CENTRAL SEROUS CHORIORETINOPATHY AND CHOROIDAL THICKNESS: A Systematic Review and Meta-Analysis

PURPOSE

Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central serous chorioretinopathy (CSCR) and subfoveal choroidal thickness changes on enhanced depth imaging optical coherence tomography.

METHODS

Systematic review and meta-analysis of all articles published up to November 2017 examining rate of OSA in patients with CSCR versus controls or examining subfoveal choroidal thickness measurements on enhanced depth imaging optical coherence tomography in patients with OSA versus controls. Pooled odds ratios and weighted mean difference with 95% confidence intervals (CIs) were calculated.

RESULTS

For the CSCR/OSA analysis, 7,238 patients (1,479 with CSCR and 5,759 controls) from 6 studies were eligible. For the choroidal thickness/OSA analysis, 778 eyes of 778 patients (514 with OSA and 264 controls) from 9 studies were eligible. Patients with CSCR had a 1.56 increased odds of having OSA than controls (odds ratio, 1.56; 95% CI, 1.16-2.10). There was no statistically significant difference in choroidal thickness between mild OSA subjects and controls (weighted mean difference = -3.17; 95% CI, -19.10 to 12.76). Patients with moderate OSA (weighted mean difference = -24.14; 95% CI, -42.16 to -6.12) and severe OSA (weighted mean difference = -51.19; 95% CI, -99.30 to -3.08) had thinner choroidal thickness measurements than controls.

CONCLUSION

In summary, our results suggest that patients with CSCR are more likely to have OSA, and that moderate/severe OSA is associated with smaller subfoveal choroidal measurements on enhanced depth imaging optical coherence tomography.

Poor Sleep Quality Is the Risk Factor for Central Serous Chorioretinopathy

Purpose

Whether sleep disturbance is related with central serous chorioretinopathy (CSC) is still in controversy. This study is designed to investigate sleep status in CSC using definite and well-established methods.

Methods

A total of 134 CSC patients and 134 age- and sex-matched normal controls were recruited in the study. Demographic data were collected through a questionnaire. Body mass index (BMI) was calculated by weight divided by height squared. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were administered to all subjects to assess the sleep quality and daytime sleepiness, respectively. Depression Anxiety Stress Scales 21-item version (DASS-21) was also used to evaluate the emotion status as a positive control. Poor sleep quality was defined as PSQI > 5 and sleep apnea tendency as ESS > 10. Positive criteria scores were ≥10 for depression, ≥8 for anxiety, and ≥15 for stress.

Results

There was no significant difference of BMI between the two groups (p=0.075). The prevalence of poor sleep quality (58.2% versus 23.9%; p < 0.001) in CSC patients was significantly higher than normal. Specifically, CSC patients presented worse performance in certain components of sleep quality, that is, sleep latency, sleep duration, and sleep efficiency. More participants had stress (23.9% versus 3%, p < 0.001), depression (25.4% versus 10.4%; p=0.001), and anxiety (28.4% versus 14.9%; p=0.008) emotions in CSC than that in normal. No significant difference was observed in sleep apnea tendency. Through logistic regression analysis, CSC patients were more likely to be in poor sleep quality (p < 0.001; OR 3.608 (2.071–6.285)) and stress emotion (p=0.002, OR 6.734 (1.997–22.711)).

Conclusion

Poor sleep quality is risk factor for CSC patients. Attention of sleep quality should be paid when treating them.

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.

Diagnosed a Patient with Central Serous Chorioretinopathy? Now What?: Management of Central Serous Chorioretinopathy

PURPOSE OF REVIEW WHAT IS THE GOAL OF YOUR PAPER? WHAT QUESTIONS DID YOU SEEK TO ANSWER?

The goal of this paper is to provide a comprehensive review of the management options for central serous chorioretinopathy (CSCR).

RECENT FINDINGS SUMMARIZE THE LATEST RESEARCH ON YOUR TOPIC

The majority of cases of acute CSCR may be managed with observation and cessation of corticosteroids, if possible, as well as life-style modifications including stress reduction and control of hypertension. The management of chronic disease is more challenging and may include either medication or laser-based treatment.

SUMMARY WHAT ANSWERS DID YOU FIND? WHAT ARE THE MAJOR TAKEAWAYS/CONCLUSIONS OF YOUR EXAMINATION? WHAT’S THE IMPACT ON FUTURE RESEARCH?

Management of CSCR necessitates an individualized and selective treatment approach. There is overall poor evidence for the use of systemic and intravitreal medications. From this class of treatments, mineralocorticoid receptor antagonists appear to have the greatest potential. Although conventional thermal photocoagulation may be used in select cases, the most promising treatment options at this time for chronic CSCR are photodynamic therapy, either half-dose or half-fluence, and non-damaging (subthreshold) retinal laser therapy.

Risk Factors for Central Serous Chorioretinopathy: Multivariate Approach in a Case-Control Study

PURPOSE

The purpose of this prospective study was to investigate the potential risk factors associated independently with central serous retinopathy (CSR) in a Greek population, using multivariate approach.

MATERIALS AND METHODS

Participants in the study were 183 consecutive patients diagnosed with CSR and 183 controls, matched for age. All participants underwent complete ophthalmological examination and information regarding their sociodemographic, clinical, medical and ophthalmological history were recorded, so as to assess potential risk factors for CSR. Univariate and multivariate analysis was performed.

RESULTS

Univariate analysis showed that male sex, high educational status, high income, alcohol consumption, smoking, hypertension, coronary heart disease, obstructive sleep apnea, autoimmune disorders, H. pylori infection, type A personality and stress, steroid use, pregnancy and hyperopia were associated with CSR, while myopia was found to protect from CSR. In multivariate analysis, alcohol consumption, hypertension, coronary heart disease and autoimmune disorders lost their significance, while the remaining factors were all independently associated with CSR.

CONCLUSIONS

It is important to take into account the various risk factors for CSR, so as to define vulnerable groups and to shed light into the pathogenesis of the disease.

Reduced Blood Serotonin Levels in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate blood serotonin (5-hydroxytryptamine [5-HT]) levels in patients with chronic central serous chorioretinopathy (CSC).

DESIGN

A case-controlled retrospective study.

PARTICIPANTS

Forty-nine patients with CSC and 30 age-matched control subjects.

METHODS

Blood 5-HT levels were measured using high-performance liquid chromatography.

MAIN OUTCOME MEASURES

Blood 5-HT levels in patients with acute or chronic CSC were measured at the initial visit and compared with those in controls.

RESULTS

The blood 5-HT level (98.2±27.5 ng/ml) in patients with chronic CSC was significantly lower than those in patients with acute CSC (122.5±23.9 ng/ml, P = 0.0081) and controls (128.5±35.8 ng/ml, P = 0.0013). After adjusting for covariates, patients with decreased blood 5-HT levels were found to be more likely to develop chronic CSC (odds ratio, 0.97; 95% confidence interval, 0.95-0.99; P = 0.009).

CONCLUSIONS

These results suggest that serotonin may have a role in chronic CSC pathogenesis and is associated with disease progression.

RISK FACTORS FOR CENTRAL SEROUS CHORIORETINOPATHY: A Systematic Review and Meta-Analysis

PURPOSE

Central serous chorioretinopathy (CSC) is a common retina disease and has a relative high recurrence rate, etiology, and pathogenesis of which remains ambiguous. The systematic review and meta-analysis aimed to measure risk factors for CSC in a quantitative method, providing some precautions and interventions on this disease and preventing further recurrences.

METHODS

A comprehensive literature review relating to risk factors for CSC through PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and VIP databases was conducted before March 2015. Odds ratio (OR) with 95% confidence interval (CI) was calculated after data combination to assess the associations between risk factors and CSC.

RESULTS

A total of 9839 patients in 17 studies were included and risk factors with significant differences found between CSC and control groups were listed as follows: hypertension (OR = 1.7; 95% CI: 1.28-2.25), Helicobacter pylori (H. pylori) infection (OR = 3.12; 95% CI: 1.81-5.40), steroid usage (OR = 4.29; 95% CI: 2.01-9.15), sleeping disturbance (OR = 1.90; 95% CI: 1.28-1.83), autoimmune disease (OR=3.44; 95% CI: 1.90-6.26), psychopharmacologic medication use (OR = 2.69; 95% CI: 1.63-4.45), and Type-A behavior (OR = 2.53; 95% CI: 1.08-5.96).

CONCLUSION

The authors concluded that hypertension, H. pylori infection, steroid usage, sleeping disturbance, autoimmune disease, psychopharmacologic medication use, and Type-A behavior were possible risk factors relating to the occurrence of CSC.

Ophthalmic Diseases in Patients With Obstructive Sleep Apnea

Symptomatic obstructive sleep apnea (OSA) affects 2% of women and 4% of men, but the prevalence of asymptomatic OSA is significantly higher. Several ophthalmic conditions are associated with OSA, including floppy eyelid syndrome, glaucoma, nonarteritic anterior ischemic optic neuropathy, papilledema, keratoconus, and central serous chorioretinopathy. The purpose of this review is to provide primary care physicians with a general knowledge of the signs, symptoms, and management of the ophthalmic diseases associated with OSA.

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.

Shift Work: A Risk Factor for Central Serous Chorioretinopathy

PURPOSE

To investigate if shift work or sleep disturbances are risk factors for central serous chorioretinopathy (CSCR).

DESIGN

Prospective case-control study.

METHODS

Forty patients with active CSCR and 40 controls (age- and sex-matched) were prospectively recruited from the Ophthalmology Department of Hôtel Dieu Hospital, Paris, between November 2013 and December 2014. All patients were asked to complete a questionnaire addressing previously described risk factors and working hours, as well as the Insomnia Severity Index (ISI), a validated instrument for assessing sleep disturbances.

RESULTS

The mean age of the CSCR group was 44 ± 9 years, whereas the mean age of the control group was 43 ± 10 years. By use of multivariate analysis, shift work (odds ratio [OR] [95% confidence interval]: 5 [1.2-20.4]; P = .02), steroid use (OR: 5.5 [1.1-26.2]; P = .03), and recent psychological stress (OR: 15.3 [4.1-54.5]; P < .001) were found to be independently associated with CSCR.

CONCLUSION

The outcomes of this study suggest that shift work is an independent risk factor of CSCR. Further studies are required to confirm these results and to examine if work reconversion would be beneficial in the treatment of patients with chronic/recurrent CSCR.

Obstructive Sleep Apnoea and Vascular Disease in Patients with Type 2 Diabetes

Obstructive sleep apnoea (OSA) is common and is associated with many vascular risk factors, such as hypertension, insulin resistance, albuminuria, dyslipidaemia, increased inflammation and endothelial dysfunction. Epidemiological studies have shown that OSA is associated with increased cardiovascular disease (CVD) and that continuous positive airway pressure (CPAP) might reduce CVD events in patients with OSA. In addition, OSA has also been shown to be associated with albuminuria, chronic kidney disease, a wide range of ocular diseases and peripheral neuropathy. Considering that CVD and microvascular complications are major contributors to the morbidity, mortality and the economic burden of diabetes and that OSA is common in patients with type 2 diabetes (T2D), it is important to understand the role of OSA in the development and/or progression of vascular disease in patients with T2D and to explore the impact of CPAP on diabetes-related vascular outcomes. The purpose of this article is to review the evidence for the relationship and impact of OSA on vascular disease and vascular risk factors particularly in patients with T2D.