Nawat WatanachaiCMU
RCOPT@Chiangmai 2013
Many names OSA : Obstructive Sleep Apnea OSAHS : Obstructive Sleep Apnea/
Hypopnea Syndrome SDB : sleep disordered breathing
Chronic transient apnea/ hypopnea
chronic recurrent ischemia
develop organ problems/ aggravate some other diseases
Floppy eyelid syndrome
Glaucoma NAION Disc edema +/- blunt eye injury
- CSCR
- DR progression
- RVO
1. Retinal findings in OSA 2. Risk for other specific retinal
diseases 3. Retinopathies in pts with known
systemic disease
1. Retinal findings in OSA
2. Risk for other specific retinal diseases
3. Retinopathies in pts with known systemic disease
In patients without known systemic disease
fundus findings Disc swelling/ NAION Thin NFL/ glaucoma AV nicking, focal arteriolar narrowing Microaneurysms, exudates, ME,
retinal hemorrhage Venous beading NVD, NVE
Sleep disordered breathing and retinal microvascular diameterShankar et al. Atherosclerosis 2012
-Wisconsin sleep cohort study-476 pts
Sleep disordered breathing and retinal microvascular diameterShankar et al. Atherosclerosis 2012
- apnea-hypopnea index (AHI)- <5 events/ h- 5-14.9 events/ h- 15> events/ h
-Outcomes- Retinal arteriolar narrowing
- mean retinal arteriolar diameter <141.0 mcm
- Retinal venular widening - mean retinal venular diameter >223.0 mcm
Sleep disordered breathing and retinal microvascular diameterShankar et al. Atherosclerosis 2012
Results-higher AHI
- positively assoc. With retinal venular dilation
- (P=0.045)- OR (compared to AHI<5 group)
- AHI5-14.9 e/h 1.31 (0.75-2.28)- AHI>15 e/h 2.08 (1.03-2.16)
- independent of BMI, HT, DM, lipid levels- no assoc. Between AHI and retinal arteriolar
narrowing (P=0.72)
Retinal Vascular Tortuosity in OSA
Mohsenin et al. Clinical Ophthalmology 2013.
Yale, Connecticut, USA 9 pts + 7 ctrls Fundus photo with Image J Digital analysis
software
Retinal Vascular Tortuosity in OSA Mohsenin et al. Clinical Ophthalmology 2013. Results : tortuosity were more in OSA
group
Independent of age, gender, BMI, DM and lipid levels
Tortousity P At 5 DD P At 10 DD
Arteriolar Not sig 0.016
Venous 0.001 0.028
total 0.011 0.004
Sleep-disordered Breathing is not Associated with the presence of retinal microvascular abnormalities: The Sleep Heart Health Study
Lori B. et al. Sleep. 2004 U of Minnesota, U of Wisconsin, JHU, U of C, U of Pittsburgh
2927 pts Retinopathy can be found more in pts with high respiratory
disturbance index (RDI) But after adjustment for age, BMI, HT, DM not significant Do not demonstrate any relation between OSA and retinal
microangiopathy
CWS in a patient with sleep apnea syndrome Kitagawa K. J Med Sci. 2003
A 55 yrs old japanese woman with OSA CWS in 2 eyes Treated with nasal continuous positive
airway pressure during sleep CWS disappeared
1. Retinal findings in OSA
2. Risk for other specific retinal diseases
3. Retinopathies in pts with known systemic disease
2. Risk for other specific retinal diseases
CSR
bilateral CSCR in a case resolved within a week of starting apnea treatment
Moghimi S et al. Sleep Med. 2012
bilateral CSCR in a case resolved within a week of starting apnea treatment
Moghimi S et al. Sleep Med. 2012
After treatment
OSA increase cathecholamine
CSCR and risk for OSA Thellea K et al. Sleep Breath. 2007.
Retrospective case-control 29 CSCR pts and 29 matched controls Increased risk for OSA
58.6% of CSCR cases 31.0% of control Odds ratio =3.67
(95%CI 1.02-13.14, P=0.046)
OSA in patients with CSCR Patrik Kloos. Graefes Arch Clin Exp
Ophthalmol. 2008 56 consecutive pts with CSCR 22% of CSCR patients were confirmed diag as
OSA Switzerland population c OSA 2-4%
2. Risk for other specific retinal diseases
RVO
Obstructive Sleep Apnea among Pts with RVO
Glacet-Bernard et al. Arch Ophthalmol. 2010.
Association between OSA and RVO Higher than expected prevalence of OSA in
pts with RVO Dysfunction in the autoregulation of 3
major blvs (PCA, CRA, OA)
Sleep apnea and risk of retinal vein occlusion: a nationwide population-based study of Taiwanese
Chou KTet al. Am J Ophthalmol. 2012
5965 sleep apnea patients vs 29 669 controls
Sleep apnea and risk of retinal vein occlusion: a nationwide population-based study of Taiwanese
Chou KTet al. Am J Ophthalmol. 2012
tendency of sleep apnea patients toward RVO (P = .048, log-rank test)
1.94-fold increase (95% confidence interval, 1.03 to 3.65; P
= .041) independent of age, gender, and co-
morbidities
1. Retinal findings in OSA 2. Risk for other specific retinal
diseases
3. Retinopathies in pts with known systemic disease
DM and DR
Obstructive sleep apnoea is associated with the development and progression of diabetic retinopathy, independent of conventional risk factors and novel biomarkers for diabetic retinopathy
Rudrappa et al. Br J Ophthalmol 2012 31 Obese DM pts
17 OSA 16 non-OSA
Obstructive sleep apnoea is associated with the development and progression of diabetic retinopathy, independent of conventional risk factors and novel biomarkers for diabetic retinopathy
Rudrappa et al. Br J Ophthalmol 2012
Results OSA group
Worse retinopathy score (p=0.04) but not maculopathy score (p=0.15) More PDR (N=4 vs 0; χ2 4.8; p=0.01).
multiple regression analysis only OSA is an independent significant predictor of the
total retinopathy scores (p=0.008)
Abnormal sleep patterns in subjects with type II DM and its effect on diabetic microangiopathies
R Raman et al. Acta Diabetol. 2012
1,414 DM patients, 136 controls Chennai, India
Age > 40Yrs old Population base cross sectional survey Look for abnormal sleep
pattern(ASP), DR
Abnormal sleep patterns in subjects with type II DM and its effect on diabetic microangiopathies
R Raman et al. Acta Diabetol. 2012
Results No association of ASP with DR in both
genders Find association of ASP with DN
Sleep Apnea in Patients with Diabetic Retinopathy
Mason et al. Retina 2012 Oxford 195 DM pts Pts with CSME
Home sleep study (ApneaLink; ResMed) Compared with control OCT/ fundus photo
Results 54% had an o2 desaturation index>10 31% had an apnea-hypopnea index >15
Impact of untreated obstructive sleep apnea on glucose control in type 2 diabetes
Aronson et al. Am J Respir Crit Care Med 2010. Performed polysomnography and
measured HbA1C in 60 DM type 2 pts Results
77% DM pts had OSA (Apnea-hypopnea index >=5)
Increase severity of OSA is associated with poorer glucose control
Nocturnal intermittent Serious Hypoxia and Reoxygenation in PDR Cases
Shiba et al. Am J Ophthalmol 2010 68 NPDR and 151 PDR Conduct pulse oximetry overnight
Nocturnal intermittent Serious Hypoxia and Reoxygenation in PDR Cases
Shiba et al. Am J Ophthalmol 2010
ResultsNPDR PDR P
4%O2 desaturation index
4.9 7.8 .007
Lowest SpO2 87.0 82.4 .0006
Cumulative % time spent at SpO2<90%
0.8 2.2 .0006
Nocturnal intermittent Serious Hypoxia and Reoxygenation in PDR Cases
Shiba et al. Am J Ophthalmol 2010
Conclusion Nocturnal hypoxia (SDB) is a risk factor for
PDR development
1. Retinal findings in OSA AV nicking, focal arteriolar narrowing ? Microaneurysms, exudates, ME, retinal hemorrhage Venous dilatation, tortuousity
2. Risk for other specific retinal diseases CSCR CRVO
3. Retinopathies in pts with known systemic disease DR
More often More aggressive
HT?