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Sleep apnea increases glaucoma progression
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Researchers found a significant correlation between severe obstructive sleep apnea and a higher risk of structural deterioration in patients with glaucoma.
In addition to its association with floppy eyelid syndrome, central serous choroidoretinopathy, retinal vein occlusions, papilledema and nonarteritic anterior ischemic optic neuropathy, obstructive sleep apnea (OSA) is a widely accepted risk factor for glaucoma, according to the study.
Researchers evaluated 32 patients who had normal tension glaucoma or primary open angle glaucoma or were categorized as glaucoma suspect. The average age at diagnosis was 50.8 ± 13.2 years, and 28 subjects were men. Twenty-four subjects were considered pre-obese, and five were obese.
The patients were stratified into two groups: no/mild OSA and moderate/severe OSA. All study subjects were followed for at least 3 years and had at least 3 consecutive reliable visual field or OCT tests.
Those with moderate/severe OSA exhibited a higher percentage of progression on visual field tests and retinal nerve fiber layer (RNFL) thickness on OCT measurements, the researchers concluded.
They also evaluated patients who were treated for OSA to determine if the treatment affected glaucoma progression. Seven were treated with continuous positive airway pressure (CPAP), and two received surgery.
According to the study, no statistically significant differences were seen in RNFL thickness or visual field tests when comparing patients who received treatment with those who did not.
Because severe OSA was linked to a higher risk of structural deterioration, the authors recommended considering possible undiagnosed severe OSA in patients with rapidly thinning RNFL or visual field deterioration despite controlled IOP. – by Nancy Hemphill, ELS, FAAO
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Richard Trevino, OD, FAAO
OSA is a common sleep disorder that has been linked to a large number of ocular conditions, including primary open angle and normal tension glaucoma.
Fan and colleagues provide us with a systematic investigation using both structural and functional criteria for progression. They found that among well-controlled glaucoma patients, those with more severe OSA demonstrated significantly greater glaucoma progression on OCT RNFL analysis without visual field progression. Furthermore, after adjusting for other risk factors, they found that glaucoma patients with severe OSA had an eight times greater risk of suffering RNFL progression compared to patients with no or mild OSA.
Interestingly, OSA treatment did not decrease the risk of glaucoma progression. RNFL progression was detected in 67% of treated patients (most with CPAP) compared with 44% of untreated patients. While this difference was not statistically significant, it does add fuel to the debate that CPAP may promote glaucoma progression by elevating nocturnal IOP.
We must approach these results with caution. The study was conducted in Taiwan and may not reflect the North American experience with OSA. It was conducted at a large tertiary care center where patients typically have more complex and advanced disease presentations. And the number of OSA patients in the study was small (27).
Despite these limitations, this study adds important new evidence linking OSA and glaucoma risk. As clinicians, we should recognize that patients with more severe OSA presentations – particularly those with floppy eyelid syndrome – have elevated glaucoma risk. The authors recommend that glaucoma patients who continue to progress despite adequate IOP control be tested for OSA. While OSA treatment may not slow glaucoma progression, it will significantly decrease systemic complications of the disease.
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