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    Something we may be missing

    Ophthalmic referrals for sleep apnea patients may be vital

    My friend, Dave, an oculoplastic surgeon and loyal Ophthalmology Times reader, trained the same time I did. He was extremely intelligent and possessed a great sense of humor. 

    A real jokester, he provided free cosmetic services to his office staff, and claimed in their presence that his treatments prevented them from frowning at him. That way, he said, whatever bad jokes or annoying comments the boss made, all he saw when he looked at his staff was happy smiling faces looking back at him.

    I use the past tense because Dave died in his 40s from complications of sleep apnea.

    Opening eyes to awareness

    Incredibly, for a disease that did not even seem to exist during my days as a medical student and intern, sleep apnea is said to affect 1 in 4 men--the prevalence in women is less than half that.

    I first became aware of this entity when, as an assistant professor in my cornea practice, I began seeing patients with inflamed tarsal conjunctivae and lax upper lids: the newly recognized floppy eyelid syndrome. Most of these patients were quite overweight and some would share that they would wake up to find their upper eyelids inverted. It never seemed (and to this day still does not seem) obvious to me that sleep apnea should manifest itself by dissolution of the tarsus.

    Of people diagnosed with keratoconus, one study found that about 1 in 5 have a history of sleep apnea (compared with only 6.5% of controls). But more than half of the keratoconus patients were found to be at high risk for sleep apnea using a questionnaire designed to detect the disease, compared with 27% of controls. Similar to the eyelid problem, I fail to see why night-breathing problems should cause corneal ectasia, but the data supporting the association seem pretty strong.

    But the sequelae of nocturnal airway obstruction are not confined to the eyelids and cornea. Reportedly, 70% to 80% of nonarteritic anterior ischemic optic neuropathy victims have sleep apnea. Interrupted breathing and resulting increased COlevels are linked to cerebral edema and resultant papilledema. These optic nerve manifestations do seem intuitively to make sense from a pathophysiologic perspective.

    Other conditions thought possibly associated with sleep apnea are open-angle glaucoma and central serous chorioretinopathy, but data supporting these associations are not conclusive.

    Case referrals

    Peter J. McDonnell, MD
    He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of ...

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      If you quiz people with spontaneous subconjunctival hemorrhages you often find symptoms of snoring and sleep apnea. Also, should consider floppy eyelid syndrome and keratoconus as associated with sleep apnea, and not necessarily a cause and effect.

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