sleep apnea and the eye - 2008
DESCRIPTION
Ocular manifestations of sleep apnea. Updated and expanded for 2008TRANSCRIPT
Sleep Apnea Sleep Apnea & the Eye& the Eye
Rick Trevino, ODRick Trevino, ODVA Outpatient ClinicVA Outpatient Clinic
Evansville, INEvansville, IN
[email protected]@gmail.com
Sleep Apnea & the EyeSleep Apnea & the Eye Sleep ApneaSleep Apnea
Sleep physiologySleep physiology Clinical consequencesClinical consequences DiagnosisDiagnosis TreatmentTreatment
Ocular Ocular ManifestationsManifestations AsthenopiaAsthenopia CPAP-assoc red eyeCPAP-assoc red eye Floppy eyelid Floppy eyelid
syndromesyndrome NAIONNAION PapilledemaPapilledema Normal tension Normal tension
glaucomaglaucoma
Online ResourcesOnline Resources
Lecture NotesLecture Notes http://richardtrevino.net/http://richardtrevino.net/
sleepapneasleepapnea
Powerpoint SlidesPowerpoint Slides http://www.slideshare.net/http://www.slideshare.net/
rhodopsinrhodopsin
Free TextsFree Texts http://jfponline.com (Aug 2008)http://jfponline.com (Aug 2008) http://pubs.nrc-cnrc.gc.ca/cjohttp://pubs.nrc-cnrc.gc.ca/cjo
Can J Ophthalmol Can J Ophthalmol 2007;42(2):238-432007;42(2):238-43
Sleep CycleSleep Cycle
Source: Graefes Arch Clin Exp Ophthalmol 2008;246:129–134
Sleep CycleSleep Cycle
PolysomnographyPolysomnography EEG channels EEG channels EOG channels EOG channels EMG channelEMG channel Nasal air current channel Nasal air current channel Thoracic motion channel Thoracic motion channel Abdominal motion channelAbdominal motion channel Oximeter channelOximeter channel Leg movement channelsLeg movement channels MicrophoneMicrophone Video recordingVideo recording
Source: N Engl J Med 2007;356:1751-1758
Sleep CycleSleep CyclePolysomnogrPolysomnogr
amam
Source: J Am Board Fam Med. 2007;20:392-398
Sleep DisordersSleep Disorders
Sleep apnea Sleep apnea InsomniaInsomnia NarcolepsyNarcolepsy Restless leg Restless leg
syndromesyndrome ParasomniasParasomnias Circadian disordersCircadian disorders Drug side effectsDrug side effects Shift workShift work
OSA is the “most physiologically disruptive and dangerous of the sleep-related disorders.”
Obstructive Sleep ApneaObstructive Sleep Apnea
Source: Thorax 2004;59:73-78
Obstructive Sleep ApneaObstructive Sleep ApneaAny Condition that Any Condition that
Causes or Contributes Causes or Contributes to Upper Airway to Upper Airway
Narrowing is a Risk Narrowing is a Risk Factor for OSAFactor for OSA
ObesityObesity
Enlarged TonsilsEnlarged Tonsils
Anatomical MalformationsAnatomical Malformations
NeoplasmsNeoplasms
Edema of the pharynxEdema of the pharynx
Lymphoid HypertrophyLymphoid Hypertrophy
Pharyngeal Muscle Pharyngeal Muscle WeaknessWeakness
Dyscoordination of Dyscoordination of Respiratory MusclesRespiratory Muscles
Source: eMedicine (http://www.emedicine.com/med/topic163.htm)
Obstructive Sleep ApneaObstructive Sleep Apnea
Excessive daytime Excessive daytime sleepinesssleepiness
Most common symptomMost common symptom
Disruptive snoringDisruptive snoring Also gasping/snorting during Also gasping/snorting during
arousalsarousals
Apneic events Apneic events witnessed by bed witnessed by bed partnerpartner
Disruptive snoring + witnessed Disruptive snoring + witnessed apneas: 94% specificityapneas: 94% specificity
ObesityObesity 30% of pts with a BMI > 30 have 30% of pts with a BMI > 30 have
OSA, and 50% of pts with a BMI > 40 OSA, and 50% of pts with a BMI > 40 have OSA.have OSA.
Neck circumferenceNeck circumference ≥≥40 cm had a sensitivity of 61% and 40 cm had a sensitivity of 61% and
a specificity of 93% for OSAa specificity of 93% for OSA Correlates better than BMICorrelates better than BMI
MaleMale 2-3x more common than female2-3x more common than female
Family history of Family history of OSAOSA
Relatives have 2-4 fold Relatives have 2-4 fold risk risk
Clinical CharacteristicsClinical Characteristics
Source: Postgrad Med 2002;111(3):70-6.
Obstructive Sleep ApneaObstructive Sleep Apnea Pickwickian SyndromePickwickian Syndrome
Obesity, daytime Obesity, daytime somnolence, loud somnolence, loud snoringsnoring
Charles Dicken’s Charles Dicken’s “Pickwick Papers” “Pickwick Papers” (1837)(1837)
Prevalence increasing Prevalence increasing in parallel with in parallel with prevalence of obesityprevalence of obesity 30-60yo: 9%F, 24%M30-60yo: 9%F, 24%M Under-diagnosedUnder-diagnosed
Source: How Stuff Works (http://healthguide.howstuffworks.com/sleep-apnea-in-depth.htm)
Obstructive Sleep ApneaObstructive Sleep Apnea
Cardiovascular Cardiovascular DiseaseDisease HTN, CAD/MI, CHF, HTN, CAD/MI, CHF,
ArrhythmiaArrhythmia StrokeStroke ObesityObesity Metabolic SyndromeMetabolic Syndrome Other DiseasesOther Diseases
Morning headache, Morning headache, EyeEye, Liver, Kidney, , Liver, Kidney, othersothers
Cognitive and Cognitive and EmotionalEmotional Impaired mental Impaired mental
functioningfunctioning DepressionDepression Mood alterationMood alteration
Effects on bed Effects on bed partnerspartners Disruptive snoringDisruptive snoring
AccidentsAccidents Drowsy drivingDrowsy driving WorkplaceWorkplace
ClinicalClinical ConsequencesConsequences
Source: Hypertension. 2003;42:1067-1074
Obstructive Sleep ApneaObstructive Sleep Apnea
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Obstructive Sleep ApneaObstructive Sleep Apnea
HistoryHistory Sleepiness assessmentSleepiness assessment Disruptive snoringDisruptive snoring Witnessed apneasWitnessed apneas
PhysicalPhysical ObesityObesity Neck circumferenceNeck circumference Throat/Mouth examThroat/Mouth exam
PSGPSG Gold StandardGold Standard Respiratory Disturbance IndexRespiratory Disturbance Index
Clinical Evaluation
Source: Sleep 1994;17:160–167
Obstructive Sleep ApneaObstructive Sleep ApneaEpworth Sleepiness ScaleEpworth Sleepiness Scale
How likely are you to doze off or fall asleep in the How likely are you to doze off or fall asleep in the following situations?following situations?
0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = 0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High ChanceHigh Chance
1. Sitting and reading1. Sitting and reading
2. Watching TV2. Watching TV
3. Sitting inactive in a public place (theater, meeting)3. Sitting inactive in a public place (theater, meeting)
4. As a passenger in a car for an hour without a break4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when 5. Lying down to rest in the afternoon when circumstances permitcircumstances permit
6. Sitting and talking to someone6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic8. In a car, while stopped for a few minutes in traffic
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Obstructive Sleep ApneaObstructive Sleep Apnea Treatment OptionsTreatment Options
Behavioral: Weight loss, EtOH avoidance, Behavioral: Weight loss, EtOH avoidance, nonsupine positionnonsupine position
Positive Airway Pressure: CPAP, othersPositive Airway Pressure: CPAP, others
Mandibular advancement deviceMandibular advancement device
Surgery: UPPP, Tonsillectomy,Surgery: UPPP, Tonsillectomy,TracheostomyTracheostomy
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness
Disruptive snoring Disruptive snoring Witnessed apneasWitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
AsthenopiaAsthenopia
Common OSA Symptoms Include:Common OSA Symptoms Include: ““Tiredness” Tiredness” ““Fatigue” Fatigue” ““Lack of energy”Lack of energy” Morning headacheMorning headache
These OSA symptoms These OSA symptoms may be misinterpreted may be misinterpreted as “eye strain”as “eye strain”
AsthenopiaAsthenopia
Common OSA-associated asthenopic Common OSA-associated asthenopic symptomssymptoms Unexplained symptoms of blurUnexplained symptoms of blur
Vision is 20/20 but the Vision is 20/20 but the patient is c/o blurpatient is c/o blur
Misinterpreting what is seenMisinterpreting what is seen Incorrect recording or Incorrect recording or
copyingcopying Eye strain and/or fatigueEye strain and/or fatigue HeadachesHeadaches
Worse in the morningWorse in the morning
AsthenopiaAsthenopia
42yo WM presents with c/o eye fatigue at 42yo WM presents with c/o eye fatigue at near.near.
LEE: <1yr with current eyeglassesLEE: <1yr with current eyeglasses
MH:MH: 1. OSA (noncompliant with CPAP)1. OSA (noncompliant with CPAP)2. Frequent HA2. Frequent HA3. Overweight3. Overweight4. Hyperlipidemia4. Hyperlipidemia5. GERD5. GERD6. Smokes 1PPD6. Smokes 1PPD
Optometric Exam: UnremarkableOptometric Exam: Unremarkable
Plan: Plan: 1. OSA management1. OSA management2. Visual hygiene2. Visual hygiene3. Smoking cessation 3. Smoking cessation
Source: JAMA 2004;291:2013-2016
AsthenopiaAsthenopia
OSA Supportive ManagementOSA Supportive Management Encourage compliance with CPAPEncourage compliance with CPAP
50% compliance rate, high drop-out rate50% compliance rate, high drop-out rate
Quit smokingQuit smoking Smokers 3 times more likely to have OSASmokers 3 times more likely to have OSA Reversible with smoking cessationReversible with smoking cessation
Weight reductionWeight reduction 10% increase in weight results in 6x greater risk of 10% increase in weight results in 6x greater risk of
developing OSA developing OSA Weight loss decreases OSA severityWeight loss decreases OSA severity
Avoid sleeping on backAvoid sleeping on back Sew golf ball into pocket on back of shirtSew golf ball into pocket on back of shirt
Avoid alcohol within 4 hours of bedtimeAvoid alcohol within 4 hours of bedtime Avoid sleeping pillsAvoid sleeping pills
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness
Disruptive snoring Disruptive snoring Witnessed apneasWitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Optometry. 2007;78:352-355
CPAP-associated Red EyeCPAP-associated Red Eye Clinical ProblemsClinical Problems
Dry eyeDry eye EXW CL intoleranceEXW CL intolerance
ConjunctivitisConjunctivitis Reactivation of RCE Reactivation of RCE
CausesCauses Air leaksAir leaks Retrograde air flow Retrograde air flow
thru nasolacrimal apparatusthru nasolacrimal apparatus
TreatmentTreatment CPAP refitting: adjust headgear and pressureCPAP refitting: adjust headgear and pressure Ointments HS, punctal plugsOintments HS, punctal plugs
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepiness, Excessive sleepiness,
disruptive snoring, disruptive snoring, witnessed apneaswitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Clin Exp Ophthalmol 2005;33:117-125.
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Clinical CharacteristicsClinical CharacteristicsEyelid hyperlaxityEyelid hyperlaxity Rubbery, easily everted Rubbery, easily everted
upper eyelidsupper eyelids Eyelash ptosis with loss of Eyelash ptosis with loss of
parallelismparallelism
Papillary conjunctivitisPapillary conjunctivitis Chronic ocular irritation, Chronic ocular irritation,
worse upon waking worse upon waking SPK, mucoid discharge SPK, mucoid discharge
commoncommon Rubbing on pillow caseRubbing on pillow case Should be suspected in any Should be suspected in any
obese pt with a chronic red obese pt with a chronic red eyeeye
Source: Ophthalmology 1998;105:165-169
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Eyelash ptosisEyelash ptosis Downward Downward
displacement of displacement of eyelasheseyelashes
Lashes may curl Lashes may curl toward the globetoward the globe
Lashes may point in Lashes may point in various directions - various directions - loss of parallelismloss of parallelism
Pts may trim with Pts may trim with scissorsscissors
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Source: Ophthalmology. 2005;112:694-704
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
PathophysiologyPathophysiology Loss of elastic fibers in Loss of elastic fibers in
tarsus and skin of lidtarsus and skin of lid Upregulation of elastin-Upregulation of elastin-
degrading enzymes degrading enzymes (matrix (matrix metalloproteinases)metalloproteinases)
Caused by repeated Caused by repeated mechanical trauma, mechanical trauma, possibly eye rubbing or possibly eye rubbing or sleeping with the face sleeping with the face buried in the pillow buried in the pillow
Source: Curr Opin Ophthalmol. 2007;18:430-433
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
TreatmentTreatment Lubrication therapyLubrication therapy
Poor lid-eye contactPoor lid-eye contact Inadequate tear distributionInadequate tear distribution
Protect eye during sleepProtect eye during sleep Ointments HSOintments HS Fox shield, patching, tapingFox shield, patching, taping
May improve or resolve May improve or resolve with CPAPwith CPAP
Surgical therapy deferred until OSA Surgical therapy deferred until OSA treatedtreated
Horizontal lid shorteningHorizontal lid shortening
Source: Clin Exp Ophthalmol 2005;33:117–125
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Relation to OSARelation to OSA Pts with FES are a Pts with FES are a
subset of all OSA subset of all OSA ptspts 96% pts with FES 96% pts with FES
have OSAhave OSA (almost 100%!)(almost 100%!)
5-15% pts with OSA 5-15% pts with OSA have FEShave FES
OSA tends to be OSA tends to be more severe in pts more severe in pts with FESwith FES
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness
Disruptive snoring Disruptive snoring Witnessed apneasWitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Rev Ophthalmol (http://www.revophth.com/index.asp?page=1_13156.htm)
NAIONNAION
Clinical Clinical CharacteristicsCharacteristics Most common acute optic Most common acute optic
neuropathy in pts >50yoneuropathy in pts >50yo Sudden painless visual loss, Sudden painless visual loss,
usually upon awakingusually upon awaking Nerve fiber bundle VF Nerve fiber bundle VF
defectsdefects Diffuse or sectoral disc Diffuse or sectoral disc
edemaedema Disc at risk:Disc at risk: small, crowded small, crowded
Mean C/D = 0.2Mean C/D = 0.2 All ≤ 0.4All ≤ 0.4
Source: http://webeye.ophth.uiowa.edu/dept/AION/Index.htm
NAIONNAION
PathophysiologyPathophysiology Idiopathic ischemic process Idiopathic ischemic process
Disorder of posterior ciliary artery circulationDisorder of posterior ciliary artery circulation Transient poor circulation in the ONHTransient poor circulation in the ONH Trigger EventTrigger Event: Fall in blood pressure below a : Fall in blood pressure below a
critical level?critical level? There is no actual blockage of the posterior ciliary There is no actual blockage of the posterior ciliary
arteriesarteries
Cascade EffectCascade Effect Mechanical crowding caused by small crowded Mechanical crowding caused by small crowded
discdisc Ischemia Ischemia Swelling Swelling Compression Compression Ischemia Ischemia
Diagnosis: Must exclude GCA in Diagnosis: Must exclude GCA in every caseevery case ESRESR C-Reactive ProteinC-Reactive Protein
Positive acute-phase proteinPositive acute-phase protein Levels increase in presence of Levels increase in presence of
inflammation inflammation Upper limit normal does not Upper limit normal does not
rise with age rise with age PlateletsPlatelets
Secondary thrombocytosis Secondary thrombocytosis due to chronic inflammationdue to chronic inflammation
NAIONNAION
NAIONNAION
TreatmentTreatment AspirinAspirin
Decreases incidence in fellow eye at 2 years, but not at 5 Decreases incidence in fellow eye at 2 years, but not at 5 yearsyears
Surgical decompressionSurgical decompression No benefit (Ischemic Optic Neuropathy Decompression No benefit (Ischemic Optic Neuropathy Decompression
Trial)Trial)
Control of predisposing systemic diseaseControl of predisposing systemic disease May slow progression or reduce incidence in fellow eyeMay slow progression or reduce incidence in fellow eye Hypertension, Diabetes, HyperlipidemiaHypertension, Diabetes, Hyperlipidemia
Avoid Avoid phosphodiesterase 5 inhibitors (Viagra, Levitra, Cialis)
May increase risk of NAION in fellow eye
NAIONNAION
Medicolegal obligation to inform pts of risk to Medicolegal obligation to inform pts of risk to fellow eyefellow eye
NAIONNAION
Relation to OSARelation to OSA Mojon (2002)Mojon (2002)
Behbehani (2005)Behbehani (2005)
Palombi (2006)Palombi (2006)
Li (2007)Li (2007)
Source: Arch Ophthalmol 2002;120:601-605
NAIONNAION
Mojon (2002)Mojon (2002) Matched case-control Matched case-control
study with 17 NAION study with 17 NAION cases and 17 controls cases and 17 controls
71% of patients with 71% of patients with NAION have OSA NAION have OSA compared with 18% of compared with 18% of controlscontrols
Can CPAP prevent Can CPAP prevent NAION in predisposed NAION in predisposed individuals with OSA?individuals with OSA?
Source: Am J Ophthalmol 2005;139:518–521
NAIONNAION
Behbehani (2005)Behbehani (2005) Report of 3 patients Report of 3 patients
that developed NAION that developed NAION while using CPAP for while using CPAP for OSAOSA
Concluded that CPAP Concluded that CPAP does not prevent does not prevent NAION in patients NAION in patients with OSAwith OSA
Questions role of OSA Questions role of OSA in development of in development of NAIONNAION
Source: Br J Ophthalmol 2006;90:879–882
NAIONNAION
Palombi (2006)Palombi (2006) 24 of 27 (89%) NAION 24 of 27 (89%) NAION
patients had OSApatients had OSA OSA was the most frequent
disorder associated with NAION
HTN: 59%HTN: 59% DM: 37%DM: 37%
Recommend all NAION Recommend all NAION pts be screened for OSApts be screened for OSA
Daytime sleepiness, noisy sleep, witnessed apneasDaytime sleepiness, noisy sleep, witnessed apneas Pickwickian habitus (obese middle-aged men)Pickwickian habitus (obese middle-aged men)
Source: Br. J. Ophthalmol. 2007;91:1524-1527
NAIONNAION
Li (2007)Li (2007) Matched case-control Matched case-control
study of 73 NAION study of 73 NAION cases and 73 controls cases and 73 controls
Administered Administered questionnaire that questionnaire that included the SA-SDQ included the SA-SDQ
22 (30.1%) cases and 13 22 (30.1%) cases and 13 (17.8%) controls had (17.8%) controls had scores consistent with scores consistent with OSAOSA
Conclude that patients Conclude that patients with OSA are at with OSA are at increased risk of NAION increased risk of NAION
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness
Disruptive snoringDisruptive snoringWitnessed apneasWitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
PapilledemaPapilledema
Clinical Clinical CharacteristicsCharacteristics Disc swelling Disc swelling
associated with associated with increased ICPincreased ICP
Symptoms of elevated Symptoms of elevated ICP: Headache, ICP: Headache, tinnitus, TOV tinnitus, TOV
Chronic papilledema Chronic papilledema (months) may lead to (months) may lead to optic atrophy and optic atrophy and vision loss vision loss
Source: Arch Ophthalmol 2000;118:1626-1630
PapilledemaPapilledema Work-upWork-up
Urgent MRI or CT scanUrgent MRI or CT scan Lumbar puncture if imaging normalLumbar puncture if imaging normal
Idiopathic Intracranial Idiopathic Intracranial HypertensionHypertension ““Pseudotumor cerebri”Pseudotumor cerebri” Syndrome of elevated ICP, Syndrome of elevated ICP,
papilledema, normal MRI/CT, papilledema, normal MRI/CT, normal CSFnormal CSF
Secondary pseudotumor cerebri Secondary pseudotumor cerebri syndromes syndromes
Venous sinus thrombosis, Venous sinus thrombosis, vitamin A toxicity, COPD, vitamin A toxicity, COPD, OSAOSA
Tx: Diamox 250mg po QID , Underlying cause if knownTx: Diamox 250mg po QID , Underlying cause if known
Source: Arch Ophthalmol 2000;118:1626-1630
PapilledemaPapilledema
Relation to OSARelation to OSA 4 pts with vision loss, 4 pts with vision loss,
unexplained disc edema unexplained disc edema and OSAand OSA
ICP is normal during the ICP is normal during the day but elevated at nightday but elevated at night
Apneas were occurring Apneas were occurring despite CPAP – require despite CPAP – require surgical txsurgical tx
Hypercapnia-induced Hypercapnia-induced cerebral vasodilatation cerebral vasodilatation elevates ICPelevates ICP
Intermittent ↑ ICP can Intermittent ↑ ICP can cause sustained cause sustained papilledemapapilledema
Papilledema resolved with Papilledema resolved with successful tx of OSAsuccessful tx of OSA
OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness
Disruptive snoring Disruptive snoring Witnessed apneasWitnessed apneas
Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Shield's Textbook of Glaucoma, 2005
Normal Tension Normal Tension GlaucomaGlaucoma
Clinical CharacteristicsClinical Characteristics Probably a variant of Probably a variant of
COAGCOAG IOP is never documented IOP is never documented
above 21 mmHg above 21 mmHg Peripapillary hemorrhages Peripapillary hemorrhages
may be more frequentmay be more frequent Peripapillary atrophy may Peripapillary atrophy may
be more marked be more marked VF defects tend to be VF defects tend to be
deeper and more localized deeper and more localized
Source: Ophthalmology 2007;114:460–465
Normal Tension Normal Tension GlaucomaGlaucoma
PathophysiologyPathophysiology NTG differs from NAION only in that NTG differs from NAION only in that
the latter is a more acute process.the latter is a more acute process. (Hayreh, 1975)(Hayreh, 1975)
Role of IOP unclearRole of IOP unclear Proven value of aggressive Proven value of aggressive
IOP lowering (CNTGS, 1998)IOP lowering (CNTGS, 1998) Pressure-independent
component also exists (LoGTS, 2007)
Source: Ophthalmology 1998;105:1866-1874
Normal Tension Normal Tension GlaucomaGlaucoma
DiagnosisDiagnosis R/O other glaucomasR/O other glaucomas
Diurnal IOP fluctuationDiurnal IOP fluctuation IOP normalization (Burnt-out IOP normalization (Burnt-out
glaucoma, pseudophakia, glaucoma, pseudophakia, steroids)steroids)
R/O other optic R/O other optic neuropathiesneuropathies
NAION, space-occupying NAION, space-occupying lesions, congenital anomalieslesions, congenital anomalies
When to order neuroimagingWhen to order neuroimaging: : Younger age (<50 yrs)Younger age (<50 yrs) Reduced VA (< 20/40)Reduced VA (< 20/40) Vertically aligned VF defectsVertically aligned VF defects Neuroretinal rim pallorNeuroretinal rim pallor
Normal Tension Normal Tension GlaucomaGlaucoma
Relation to OSARelation to OSA Glaucoma Patients with OSA (50-60% NTG pts have OSA)
Mojon (2000)Mojon (2000) 20% (POAG)20% (POAG)
Marcus (2001)Marcus (2001) 57% (NTG)57% (NTG)
Mojon (2002)Mojon (2002) 50-60% (NTG, varies with 50-60% (NTG, varies with age)age)
OSA Patients with Glaucoma (5-10% OSA pts have NTG)
Mojon (1999)Mojon (1999) 7%7%
Geyer (2003)Geyer (2003) 2%2%
Sergi (2007)Sergi (2007) 6% (NTG)6% (NTG)
Bendel (2007)Bendel (2007) 27%27%
Karakuck (2008)Karakuck (2008) 10% (NTG), 3% (POAG)10% (NTG), 3% (POAG)
Normal Tension Normal Tension GlaucomaGlaucoma
OSA May Cause VF Loss Without GlaucomaOSA May Cause VF Loss Without Glaucoma VF loss may occur due to optic nerve damage VF loss may occur due to optic nerve damage
caused by cerebral ischemia and intermittent ICP caused by cerebral ischemia and intermittent ICP elevationelevation
Batisse (2004)Batisse (2004) Eye exam on 35 consecutive patients undergoing PSG Eye exam on 35 consecutive patients undergoing PSG VF mean deviation correlated with RDIVF mean deviation correlated with RDI
Tsang (2006)Tsang (2006) Compared VF and ONH changes between 41 pts with Compared VF and ONH changes between 41 pts with
moderate-severe OSA with 35 age-matched controls moderate-severe OSA with 35 age-matched controls In OSA pts the VF indices were significantly subnormalIn OSA pts the VF indices were significantly subnormal
Karakucuk (2008) Karakucuk (2008) Eye exams and orbital blood flow studies on 31 pts with Eye exams and orbital blood flow studies on 31 pts with
OSA and 25 normal control subjects OSA and 25 normal control subjects VF defects were detected in 10 pts despite normal eye VF defects were detected in 10 pts despite normal eye
exam. exam.
Source: Invest Ophthalmol Vis Sci. 2008;49:934–940
Normal Tension Normal Tension GlaucomaGlaucoma
CPAP Increases IOPCPAP Increases IOP Kiekens (2008)Kiekens (2008)
Diurnal IOP in 21 OSA Diurnal IOP in 21 OSA pts with and without CPAPpts with and without CPAP
Average IOP and diurnal Average IOP and diurnal fluctuation higher with CPAP fluctuation higher with CPAP
30 min after CPAP cessation 30 min after CPAP cessation a significant decrease in IOP a significant decrease in IOP was recorded was recorded
Speculate that CPAP elevates intrathoracic pressure, leading to higher central venous pressure, and ultimately higher IOP
Recommend regular screening of VF and the optic disc for all patients with OSA, especially those treated with CPAP
Source: Can J Ophthalmol 2007;42:238–243
Thank You!Thank You!