Eyeworld

EW NEWS & OPINION January 2017 27 by Vanessa Caceres EyeWorld Contributing Writer These can help determine a patient's risk for OSA, Dr. West said. Not all patients with eye disorders like glaucoma need to have a sleep study. However, if the suspicion is raised, refer them to their primary care doctor or a sleep specialist. "I will have them talk to their primary care physician and have them order the sleep study and follow up. Just recently, I had a patient with diabetes, glaucoma, and who was slightly overweight but had never been asked about sleep apnea. I have a strong suspicion that she has sleep apnea," said Dr. Burgos, using this case as an example of the kind of patient you may see with OSA. Other factors that make Dr. Burgos more likely to refer a patient include excess weight, male sex, and a thick neck. With the prevalence of continu- ous positive airway pressure (CPAP) devices, treatment for OSA nowa- days is easier. The use of CPAP could help lower the risk for the afore- mentioned eye disorders. "CPAP for OSA improves blood pressure in people with hypertension, improves the intermittent hypoxic dips and the recurrent pulse rate arousals, all of which may be good for retinal health—although research on this is lacking," Dr. West said. The ROSA study, due for publication this year, should provide more facts in this area, she said. Another reason that ophthal- mologists should remain vigilant for The authors of the studies included in the review all noted that more prospective studies to link eye disorders and OSA are needed; with- out those, only limited conclusions can be made about the association between the two areas, Dr. West said. In addition to eye disorders, those with OSA are at greater risk for certain systemic problems, such as hypertension, stroke, myocardial infarction, atrial fibrillation, and diabetes. Back in the clinic So what should ophthalmologists do to help assess whether a patient may have OSA? The first step is to have a low threshold to ask questions related to OSA symptoms, Dr. Dasgupta said. Sleep studies are now com- mon; a number of patients can even qualify for home-based sleep studies, so they're not tethered to devices and wires used in a sleep lab. "The home-based studies have changed the game," he said. "Eye professionals can ask ques- tions about a person's general sleep- ing habits, somnolence during the day, sleep problems, and snoring," said Francisco Burgos, OD, Katzen Eye Group, Baltimore. Or there are a number of online question- naires that ophthalmologists can offer patients, such as the Epworth Sleepiness Scale (www.slhn.org/docs/ pdf/neuro-epworthsleepscale.pdf) or the STOPBang Questionnaire (www. stopbang.ca/osa/screening.php). Studies find links between sleep apnea and eye disorders Y our patient examination naturally focuses on the eyes—but are you also asking patients about how they sleep? This seemingly off-the-wall question actually has a lot of poten- tial relevance to a patient's ocular and overall health. That's because an increasing amount of research finds certain eye disorders are linked to obstructive sleep apnea (OSA). Sleep apnea, or when a pa- tient stops breathing briefly during sleep—often several times during the night—affects 15 to 20 million peo- ple in the U.S., said Raj Dasgupta, MD, assistant professor of clinical medicine, Keck School of Medicine, University of Southern California, Los Angeles. The prevalence of OSA is in- creasing along with the rise in obe- sity. However, not all patients with OSA are overweight or obese, Dr. Dasgupta said. There's also a general rise in all types of sleep disorders as people try to scrimp by on less sleep. "Many people watch their diet but they forget about [what hap- pens] the whole time when they are sleeping," Dr. Dasgupta said. Eyes and sleep apnea A review article published in 2016 analyzed some of the eye disorders commonly associated with OSA. 1 The article considered studies related to OSA and glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, floppy eyelid syn- drome, age-related macular degener- ation, and diabetic retinopathy. The exact association between OSA and eye disorders remains under inves- tigation and can vary depending on the individual condition. "The connection seems stron- gest for diabetic eye disease, includ- ing diabetic macular edema," said study coauthor Sophie West, MD, Newcastle Regional Sleep Service, Newcastle Upon Tyne Hospitals, NHS Trust, Newcastle, England. "The large population studies for glauco- ma also appear compelling." Don't sleep on the job and miss this diagnosis OSA is because it is less likely that sleep specialists will examine for eye disorders due to the setup of a typ- ical exam with an OSA suspect pa- tient. "The ideal sleep clinic would have health care professionals who look after OSA, along with weight management, exercise specialists, and hypertension specialists," Dr. West said. Even cardiologists and diabetes specialists could be part of the treatment paradigm because those with OSA are at a greater risk for cardiovascular disease, type 2 di- abetes, and non-alcoholic fatty liver disease. However, this setup does not currently exist in the U.K. Although a problem like floppy eyelid syndrome may be evident to a sleep specialist, other disorders require a dilated exam from an oph- thalmologist to detect, Dr. Dasgupta said. Once OSA is treated, eye pro- fessionals should keep the disease on their radar because CPAP devices can occasionally cause dry eye, said Steve Safran, MD, Lawrenceville, New Jersey. The IOP of glaucoma patients using CPAP can fluctuate, which is another reason for eye pro- fessionals to remain vigilant about OSA and CPAP use, Dr. Burgos said. Ultimately, the need to track OSA and eye disorders falls into the bigger picture of eye disorders connected to sleep issues, said Dr. Safran, who has a long-time interest in this area. "Patients aren't used to people asking about sleep, but it's very important," he said. EW Reference 1. West SD, et al. Eye disorders associated with obstructive sleep apnoea. Curr Opin Pulm Med. 2016;22:595–601. Editors' note: The physicians have no financial interests related to their comments. Contact information Burgos: fburgos@katzeneye.com Dasgupta: rdasjupt@usc.edu Safran: safran12@comcast.net West: sophie.west@nuth.nhs.uk

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