Is Obstructive Sleep Apnea Associated With Progressive Glaucomatous Optic Neuropathy?

Primary open-angle glaucoma in patients with obstructive sleep apnoea in a Colombian population: a cross-sectional study

OBJECTIVE

Determine the prevalence, functional and structural alterations of primary open-angle glaucoma (POAG) in patients with obstructive sleep apnoea (OSA).

DESIGN

Cross-sectional.

SETTING

Tertiary hospital associated with specialised center in ophthalmologic images in Bogota, Colombia.

PARTICIPANTS

150 patients, for a sample of 300 eyes, 64 women (42.7%) and 84 men (57.3%) between 40 and 91 years old with a mean age of 66.8 (±12.1) years.

INTERVENTIONS

Visual acuity, biomicroscopy, intraocular pressure, indirect gonioscopy and direct ophthalmoscopy. Patients classified as glaucoma suspects underwent automated perimetry (AP) and optical coherence tomography of the optic nerve OUTCOME MEASURE: The primary outcomes are the determination of prevalence of glaucoma suspects and POAG in patients with OSA. Secondary outcomes are the description of functional and structural alterations in computerised exams of patients with OSA.

RESULTS

The prevalence of glaucoma suspect was 12.6%, and for POAG was 17.3%. No alterations in the appearance of the optic nerve was seen in 74.6%, focal or diffuse thinning of the neuroretinal rim (16.6%) was the most frequently finding, followed by asymmetry of the disc>0.2 mm (8.6%) (p=0.005). In the AP, 41% showed arcuate, nasal step and paracentral focal defects. The mean retinal nerve fiber layer (RNFL) was normal (>80 µM) in 74% of the mild OSA group, 93.8% of the moderate group and 17.1% of the severe group. Similarly, normal (P5-90) ganglion cell complex (GCC) in 60%, 68% and 75%, respectively. Abnormal results in the mean RNFL was seen in 25.9%, 6.3% and 23.4% of the mild, moderate and severe groups, respectively. In the GCC, 39.7%, 33.3% and 25% of the patients in the aforementioned groups.

CONCLUSION

It was possible to determine the relationship between structural changes in the optic nerve and the severity of OSA. No relationship with any of the other studied variables was identified.

Glaucoma Is Associated with the Risk of Obstructive Sleep Apnea: A Population-Based Nationwide Cohort Study

The association between glaucoma and the risk of obstructive sleep apnea (OSA) has not been fully evaluated. Therefore, this study aimed to investigate the prospective association between glaucoma and OSA. In total, 1437 patients with glaucoma and 5748 patients without glaucoma were enrolled after 1:4 propensity score matching using a nationwide cohort sample. We investigated OSA events during a 10-year follow-up period. Survival analysis, the log-rank test, and Cox proportional hazards regression models were used to calculate the incidence, disease-free survival rate, and hazard ratio (HR). The incidence of OSA was 12,509.0 person-years among those with glaucoma. The adjusted HR for patients with glaucoma developing OSA events during the follow-up period was 1.52 (95% confidence interval [CI]: 0.64-3.621) after other covariates. In a subgroup analysis, primary angle-closure glaucoma (PACG) showed a significantly increased adjusted HR for OSA events (5.65, 95% CI: 1.65-19.41), whereas we could not find any significant association between primary open-angle glaucoma (POAG) and OSA. The adjusted HR of OSA events in POAG was considerably increased 4 years after POAG diagnosis. PACG may be associated with an increased incidence of OSA. Clinicians should pay attention to early detection of OSA in patients with PACG.

A Narrative Review of the Association between Obstructive Sleep Apnea and Glaucoma in Adults

BACKGROUND

Obstructive sleep apnea (OSA) is a sleep disorder, primarily of the upper airway, which not only has a significant impact on quality of life but is also associated with various systemic diseases. Several ophthalmological diseases are also associated with OSA, especially glaucoma. The purpose of this review is to take a closer look at the causality and mutual influence.

METHODS

A systematic literature search was conducted using PubMed. A total of 19 studies with 316,178 adult participants were included.

RESULTS

Eleven of the sixteen studies concentrating on the prevalence of glaucoma in patients with OSA showed an association of both entities. One paper found a higher risk for progression of glaucoma in OSA patients. Five of the sixteen included studies failed to show a correlation between OSA and glaucoma. One study out of three surveying specific ophthalmological parameters showed an influence of OSA therapy on retinal nerve fiber layer (RNFL) thinning and vision. One study showed a rise in intraocular pressure (IOP), while two other studies showed no increase under continuous positive airway pressure (CPAP).

CONCLUSIONS

Our findings suggest an association between OSA and glaucoma and, especially, between OSA and thinning of RNFL. CPAP therapy appears to be also suitable for patients with comorbid glaucoma.

Association of obstructive sleep apnea/hypopnea syndrome with glaucomatous optic neuropathy and ocular blood flow

The present study aimed to investigate the prevalence of glaucomatous optic neuropathy in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). In total, 83 subjects (45 cases of severe OSAHS and 38 controls) underwent polysomnographic assessment and were evaluated for the severity of the disease using the Apnea-Hypopnea index. A detailed ophthalmologic exam was then performed, including measurement of the intraocular pressure (IOP) with a Goldmann applanation tonometer and Pascal dynamic contour tonometer (DCT), recording of the ocular pulse amplitude measured by the Pascal DCT, standard automated perimetry and retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) thickness evaluation using optical coherence tomography. Ocular blood flow was assessed using color Doppler imaging (CDI) and ophthalmic artery indices were evaluated, including peak systolic blood velocity, end diastolic blood velocity and resistivity index (RI). There was a significant difference in the mean IOP between controls (11.03±3.85 mmHg) and cases of severe OSAHS (18.06±3.39 mmHg) when the IOP was measured by DCT (P<0.0001), but not with the Goldmann applanation tonometer (IOP, 13.97±2.85 mmHg for controls and 14.89±3.21 mmHg for cases of severe OSAHS; P=0.0877). Significant negative correlations were observed between RNFL thickness and RI (P=0.0011) in cases of severe OSAHS, as well as between GCC thickness and RI (P<0.008) in all subjects. Furthermore, a negative correlation between RI and RNFL thickness in severe cases of OSAHS suggested a hemodynamically induced vulnerability of RNFL in OSAHS. The correlation between RI and GCC thickness in all subjects suggested that impaired perfusion, more prominent in OSAHS, leads to structural changes. Therefore, cases of severe OSAHS should be monitored for changes in RNFL and GCC thickness, as well as CDI findings. Furthermore, patients with increased ophthalmic artery RIs should be monitored for changes in the GCC, regardless of the etiology of the RI increase.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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