Something we may be missing

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 CO² levels 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

Case referrals

I miss Dave, and feel badly that I or someone else didn’t pick up on what was happening much earlier in the progression of his sleep apnea. He did have some extra pounds on board, but a lot of us men physicians lead fairly sedentary lives in our exam rooms and operating rooms and I never thought of him as particularly obese. And a lot of folks with sleep apnea are not obese.

But what occurs to me is that, considering this is a disease that apparently afflicts 1 in 4 men, there are very few patients who I end up referring for workup of possible sleep apnea. I am probably missing a fair number of patients with this problem, because I am not routinely thinking about it unless a patient presents to me with floppy eyelid syndrome or keratoconus.

Ophthalmologists seeing 40 patients per day should expect to see a handful of already diagnosed patients or refer that number each day for evaluation. If not, we’re probably blissfully ignorant of the problem in many of our patients.

References

McNab AA. The eye and sleep apnea. Sleep Med Rev. 2007;11:269-276.
Saidel MA et al. Prevalence of sleep apnea syndrome and high-risk characteristics among keratoconus patients. Cornea. 2012;31:600-603.