Obstructive sleep apnea (OSA), also referred to as “sleep-disordered breathing” and “sleep-related breathing disorder,” is a pulmonary condition characterized by repetitive collapse of the upper airway, which often leads to snoring, episodes of sleep interruption, hypoxemia, hypercapnia, fluctuations in intrathoracic pressure, and increased sympathetic activity (Sharma et al, 2015). OSA is associated with increased risk for hypertension, stroke, cardiovascular events, altered cardiovascular function, insulin resistance, cancer, vascular endothelial dysfunction, elevated systemic inflammatory markers, and increased platelet aggregation (Morsy et al, 2019; Mayo Clinic).

OSA affects males more than females, and individuals who have OSA are at increased risk for a number of ocular conditions including floppy eyelid syndrome (FES), keratoconus, retinal vascular tortuosity and congestion, non-arteritic ischemic optic neuropathy, glaucoma, papilledema, retinal visual field defects, and reduced tear film breakup time (Sharma et al, 2015). OSA has been recognized for its potential to negatively impact the ocular surface (Sharma et al, 2015).

At Risk for Other Conditions

Morsy and colleagues (2019) evaluated a predominantly Arab population for OSA-associated ocular complications. They conducted an exhaustive battery of ocular tests including unaided and best-corrected visual acuities, refraction, slit lamp evaluation anterior photography intraocular pressure, dilated fundus examination and photography, fluorescein angiography, and visual field assessment. They determined that individuals who had OSA were at greater frequencies of senile cataract, normal tension glaucoma, retinal ischemia, conjunctival hyperemia, and dry eye. They also found 15% of normal subjects had dry eye disease (DED), while 45% of OSA subjects had some degree of dry eye.

The American Academy of Sleep Medicine guidelines encourages the use of medical devices, such as continuous positive airway pressure (CPAP) or other nasal mask therapy (NMT) devices, during sleep (Patil et al, 2019). In a three-year study, Matossian and colleagues (2020) evaluated the relationship between the incidence rates (IR) and prevalence rates (PR) of DED in adults using CPAP or NMT devices in the management of sleep apnea. Compared with the incidence of DED in the general United States population, the incidence of DED was higher in patients who used CPAP or NMT devices, particularly starting in the second year of use.

The Side Effects of Treatment

This information is valuable to practitioners who manage DED. OSA increases the risk for numerous systemic conditions and CPAP and similar devices are beneficial in its management, but these devices are not without their own issues. They have significant potential to exacerbate numerous ocular conditions, particularly DED (Matossian et al, 2020). Because the risk for ocular complications secondary to use of these devices increases exponentially over time, a thorough dry eye-directed case history—including the use of “breathing devices,” patient education, and ongoing evaluation for DED—is essential in the long-term management of these individuals. CLS

References

1. Sharma SK, Katoch VM, Mohan A, et al. Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014. Lung India. 2015 Jul-Aug;32:422-434.
2. Morsy NE, Amani BE, Magda AA, et al. Prevalence and Predictors of Ocular Complications in Obstructive Sleep Apnea Patients: A Cross-sectional Case-control Study. Open Respir Med J. 2019 Jul 31;13:19-30.
3. Mayo Clinic. Obstructive sleep apnea. Available at mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090 . Accessed May 24, 2022.
4. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of sleep medicine clinical practice guideline. J Clin Sleep Med. 2019 Feb 15;15:335-343.
5. Matossian C, Song X, Chopra I, Sainski-Nguyen A, Ogundele A. The Prevalence and Incidence of Dry Eye Disease Among Patients Using Continuous Positive Airway Pressure or Other Nasal Mask Therapy Devices to Treat Sleep Apnea. Clin Ophthalmol. 2020 Oct 15;14:3371-3379.