April 2009




Opening eyes to an ophthalmic sleep apnea

by Maxine Lipner Senior EyeWorld Contributing Editor



Patients with disorders from glaucoma to floppy eyelid syndrome may share one connection—sleep apnea

Sleep disorders may have some unfortunate ophthalmic consequences, with obstructive apnea patients often also plagued by problems such as glaucoma, nonarteritic anterior ischemic optic neuropathy, floppy eyelid syndrome and papilledema. In a recent review article published in the November 2008 issue of Mayo Clinic Proceedings, investigators found significant links between eye disease and sleep apnea, according to E. Andrew Waller, M.D., pulmonologist and sleep specialist, Mayo Clinic, Rochester, Minn. The review study evolved out of an ongoing curiosity about the impact of sleep disorders. “I’ve always had an interest in sleep and its relationship to physiologic problems,” Dr. Waller said. “Also, two of the other authors on the article had done a study previously looking at the prevalence of glaucoma in patients with sleep apnea.”

Investigators here cast a fairly wide net in looking through the literature. “We started out looking at general sleep disorders and the eye and then refined our search to find prevalence studies,” Dr. Waller said. “But for many associations there really weren’t any prevalence studies.”

Eyeing associations

However, in reviewing the available studies several interesting associations did come to light. “We did find that several studies have described a potential relationship with floppy eyelid syndrome, with glaucoma, with nonarteritic anterior ischemic optic neuropathy, and with the clinical exam finding of papilledema,” Dr. Waller said. “The most powerful associations appear to be with floppy eyelid syndrome and with glaucoma.” The numbers here are telling. “It appears that close to 100% of patients with floppy eyelid syndrome have sleep apnea,” Dr. Waller said. “It also appears that about 20 to 30% of patients with glaucoma have obstructive sleep apnea, which is higher than the general population, which is about 5%.” Likewise, when looking at it from the side of those diagnosed with sleep apnea, the incidence of glaucoma has been shown to be as high as 27%. While no significant research has been done to explore why this association may exist, most of the theories center around the vascular effect of sleep apnea. “Sleep apnea is associated with increased risk for stroke, increased risk for ischemic heart disease, and the eye has a very sensitive blood supply as well,” Dr. Waller said. “It’s thought that particularly in the relationship with glaucoma, there may be some effects with the low oxygen at night and vascular effects.” This vascular connection may extend to floppy eyelid syndrome as well. “With floppy eyelid syndrome this may mean a very similar situation where vascular insults increase inflammatory effects,” Dr. Waller said. This together with mechanical effects may cause the problem.

However, Dr. Waller admits that the association has not been well studied. “The best guess is that this may be related to some vascular effects of sleep apnea causing an increased incidence of these disorders in patients,” he said.

Ophthalmic monitoring

From a clinical perspective Dr. Waller saw the study as a chance to increase awareness of the potential link to sleep apnea. “People are very aware of the risk of heart problems and stroke with sleep apnea, but not many people realize that there are risks to the eye in relation to sleep disorders,” he said. He recommends that patients who have sleep apnea take ophthalmic monitoring seriously. “Someone with sleep apnea might benefit from having a routine eye exam, which would include screening for glaucoma,” he said. “Also, people who have floppy eyelid syndrome should be evaluated for sleep apnea because close to 100% are going to have the disorder.” In addition, this could be important for floppy eyelid treatment. “At least one of the [study] authors has found that some people are refractory to treatment directed at the floppy eyelid syndrome when they haven’t had their sleep apnea taken care of,” Dr. Waller said.

In cases where patients have floppy eyelid syndrome, if they have not been diagnosed with apnea they may wish to be tested for this. “Most patients have severe sleep apnea, but not everyone who has severe sleep apnea realizes that he has a problem,” Dr. Waller said. “Although there are a lot of symptoms that suggest a problem, not all come to clinical awareness.”

Symptoms of sleep apnea potentially include snoring, excessive daytime sleepiness or fatigue, morning headaches for some, and also insomnia. Many times bed partners will also observe that patients’ breathing ceases for short periods, Dr. Waller said.

Overall, Dr. Waller sees the association between sleep apnea and ophthalmic diseases such as glaucoma and floppy eyelid syndrome as an interesting one. “I think that more research needs to be done to figure out where the physiologic connection is between these two problems,” he said. “I think that it would probably help our understanding both of the physiologic effects of sleep apnea as well as the underlying etiologies for those two disorders.”

Editors’ note: Dr. Waller has no financial interests related to his comments.

Contact information

Waller: 507-255-6276, waller.ernest@mayo.edu

Opening eyes to an ophthalmic sleep apnea Opening eyes to an ophthalmic sleep apnea
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