Ocular surface altered in subjects with untreated obstructive sleep apnea
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Individuals with moderate/severe obstructive sleep apnea more commonly had floppy eyelid syndrome, shorter tear breakup time and higher ocular redness scores than those with normal/mild OSA, according to a study.
Previous research has evaluated systemic disease in those with untreated obstructive sleep apnea (OSA) and “the associations between tear film disorders and OSA, but did not objectively assess the changes of ocular surface in OSA patients,” Pei-Wen Lin, of the division of glaucoma, department of ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan, and colleagues wrote in Nature and Science of Sleep.
The researchers sought to evaluate these issues in untreated patients with OSA and normal control subjects and analyze any correlations in depth.
One hundred eighty-one participants underwent polysomnography to determine the occurrence and severity of their OSA; received the Ocular Surface Disease Index (OSDI) questionnaire, ophthalmic exams, measurement of tear meniscus height and noninvasive tear film breakup time testing; and were evaluated for ocular surface redness, endothelial cell density and corneal fluorescein staining.
Floppy eyelid syndrome was found in 11.5% of the control group, 45.3% of the mild OSA group, 45.2% of the moderate OSA group and 60% of the severe OSA group, with significant differences among the groups in tear breakup time and redness scores. No significant differences were seen in the OSDI, tear meniscus height, central corneal thickness, endothelial cell density, Schirmer test or corneal staining.
“If the hypoxia causes ocular surface inflammation and damage, longer duration and greater severity of OSA will result in greater changes of ocular surface,” the researchers said. “Longitudinal evaluations of ocular surface change and tear film performance, including meibomian gland dysfunction and tear osmolarity, can be necessary in patients with OSA.”
Perspective
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Previous studies have shown increased rates of dry eye disease among patients with obstructive sleep apnea. This study was able to show that more severe untreated obstructive sleep apnea is correlated with more severe ocular surface findings.
An increased rate of floppy eyelid syndrome in this population is not novel, but the study was able to show a correlation between increased conjunctival hyperemia and tear film breakup time, which may help clinicians make appropriate referrals for patients who appear to have untreated sleep apnea.
As we know, sleep apnea has also been associated with hypertension, stroke, nonarteritic ischemic optic neuropathy and sudden death. It would be appropriate to refer a patient without known sleep apnea to their primary care physician in the setting of floppy eyelid syndrome and ocular surface disease, particularly if they also admit to other sleep apnea symptoms.
The major shortcoming of this study was sample size. In particular, more patients with severe untreated obstructive sleep apnea were included than any other group, which may cause bias in the collected data. Furthermore, additional investigation into the relationship between changes in the meibomian glands and the severity of sleep apnea is needed.
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