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?