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EW NEWS & OPINION 28 October 2017 by Liz Hillman EyeWorld Staff Writer background retinopathy at baseline, who are typically at increased risk of progression compared to patients with no retinopathy," Dr. Tahrani said, adding that it could be useful to repeat the study in a lower risk population and for a longer follow- up period. Obstructive sleep apnea has been implicated as causing or con- tributing to other ophthalmic diseas- es or conditions as well, including floppy eyelid syndrome, papillede- ma, glaucoma, and nonarteritic an- terior ischemic optic neuropathy. 2–5 Nina Ni, MD, Eye Care Insti- tute, Santa Rosa, California, said that while sleep apnea is not a condition asked about on her pre-appointment questionnaire—many patients, she noted, don't even know they have it—as a cornea and external disease specialist, she gets a lot of referrals for lid issues. "We know that OSA is associ- ated with floppy eyelid syndrome. Sometimes when patients are sleep- ing, the eyelid may evert and can rub and often times they get an up- per lid reaction when it's so lax," Dr. Ni said. "[Sleep apnea] is always on my radar for that reason, and I think that it's also on the general ophthal- mologist's radar for that reason." Dr. Ni will counsel these pa- tients to use lubrication at night—a thick ointment or gel artificial tears —and might even advise them to tape their lid shut. If this is too conservative of a treatment, she might refer them to an oculoplastic surgeon. As for the sleep apnea, which can have other systemic effects, Dr. Ni said she will include that a sleep evaluation might be a worthwhile workup in her letter to the patient's primary care physician. "Individuals with OSA have a dramatically increased preva- lence and severity of potentially sight-threatening, proliferative dia- betic retinopathy and maculopathy due to a multifactorial combination of obesity, glucose intolerance, glu- cose resistance, metabolic distur- bances, and systemic hypertension— all of which individually and more so in damaging combinations can precipitate diabetic retinopathy," said Alan Mendelson, MD, Eye The longitudinal study from two U.K.-based diabetes clinics involved 230 patients, 36.1% of whom had sight-threatening diabet- ic retinopathy and 63.9% had OSA. Sight-threatening diabetic retinopa- thy was more prevalent in patients with OSA (42.9%) compared to those without OSA (24.1%). The median follow-up period was 42.0 months, and the re- searchers found that patients with OSA were more likely to develop pre-proliferative or proliferative DR compared to patients without OSA (18.4% compared to 6.1%). Patients who were treated with continuous positive away pressure were less likely to develop pre-proliferative or proliferative DR. Dr. Tahrani noted that the pa- tients included in the study were a higher risk population with multiple risk factors for diabetic retinopathy progression. "… it is worth noting that the vast majority of progres- sion occurred in patients who had of diabetes-related microvascular complications including DR," said Abd Tahrani, MD, clinician scien- tist, National Institute for Health Research, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, U.K. "Hy- poxemia, oxidative stress, inflamma- tion, endothelial dysfunction, and hypertension all play an important role in the pathogenesis of DR. OSA is associated with multiple DR risk factors, including intermittent oxygen desaturations, increased in- flammation and oxidative stress, and endothelial dysfunction. Hence, we hypothesized that OSA was linked to DR. "As tissue, hypoxia and vascular endothelial growth factor (VEGF) play important roles in the devel- opment of pre-proliferative and proliferative DR, we were expecting that OSA—with it associated hypox- emia—would result in the develop- ment of advanced DR," Dr. Tahrani said. Those with both diabetes and OSA were at greater risk of developing diabetic retinopathy within 4 years N ew research is reminding ophthalmologists about the importance of consid- ering the effect of a pa- tient's quality of sleep on ocular disease and probing deeper if patients report having symptoms that might be indicative of obstruc- tive sleep apnea (OSA), especially if they're diabetic. Research published in the American Journal of Respiratory and Critical Care Medicine found that patients with type 2 diabetes and OSA had a greater risk of developing sight-threatening diabetic retinopa- thy (DR) in 4 years or less. 1 "OSA and hyperglycemia have similar molecular consequences that can lead to the development Study links obstructive sleep apnea in type 2 diabetes patients to higher risk for sight-threatening condition Research highlight

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