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SLEEP APNEA AND THE Sara Nonhof, O.D.

Floppy Syndrome First described in 1981

Definition: • easily everted eyelids • chronic papillary • found in obese, milddle-aged men

Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Medicine. 2006;7:117-22

PATHOGENESIS

 Mechanical theory

 Decreased tarsal elastin

 Lid laxity

 Tear film abnormalities/Meibomianitis

 Chronic inflammation

 Alterations in collagen

http://utahoc.com/floppy-eyelid-syndrome-sleep-apnea/

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OCULAR ASSOCIATIONS

 Eyelids

OCULAR ASSOCIATIONS: EYELIDS

 Function: protect ocular surface

 Become easily distorted and everted http://www.drvisionworld.com/demodex-infestation/  Other pathologies reported   Blepharochalasis  Upper lid lash ptosis  /, Meibomianitis, Demodex

http://optometrist.com.au/blepharochalasis/

OCULAR ASSOCIATIONS: CONJUNCTIVA

 Chronic papillary conjunctivitis

 Hallmark sign

 Epithelial and stromal changes are non-specific

 May delay in diagnosis http://www.improveeyesighthq.com/giant-papillary-conjunctivitis.html

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OCULAR ASSOCIATIONS: CORNEA

 Punctate epithelial keratopathy  Most common finding  Diffuse  Typically only involves affected eye

 Study published in Cornea in May 2015  FES patients have lower CH values

http://www.djo.harvard.edu/print.php?url=/physicians/oa/779  Subepithelial scarring

 Deep neovascularization

OCULAR ASSOCIATIONS: GLAUCOMA

 FES as an Indicator of the Presence of Glaucoma in Patients with OSA  Published in J Glaucoma in January 2014  152 patients  Prevalence of glaucoma  Total: 12.9%  With FES: 23.07%  Without FES: 5.3%  Possible that elastic fiber depletion may cause changes to lamina cribosa or TM  Advise screening patients with FES for glaucoma

SYSTEMIC ASSOCIATIONS

 Obesity

 Obstructive sleep apnea-hypopnea syndrome

 Hypertension

 Diabetes mellitus

 Ischemic heart disease

 Hyperlipidemia

 Skin pathologies

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OSAHS

 Clinical definition  Partial or complete closure of upper airway despite ongoing respiratory effort  Leads to recurrent arousals, intermittent hypoxemia, and sleep fragmentation

 Prevalence  3-7% among adult men  2-5% among adult women

 Risk Factors  Male sex  Obesity  Advanced age

OSAHS

 Linked to an increase in cardiovascular and cerebrovascular morbidity and mortality

 Diagnosed with polysomnography

 Treatment  Weight loss  CPAP http://www.cpap.com/cpap-faq/Masks.html  Positional therapy  Surgical intervention

FES AND OSAHS

 Several studies linking the two conditions

 Originally thought to affect obese male only

 If FES is present, but OSAHS undiagnosed, consider referral for a polysomnography

 Prevalence

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“Although the prevalence of floppy eyelid syndrome in patients in OSAS is relatively low, 4.5%-5.0%, OSAS is seen in 96%-100% of patients with floppy eyelid syndrome.”1

1. Waller EA, Bendel RE, Kaplan J. Sleep disorders and the eye. May Clin Proc. 2008;83:1251-61.

DIAGNOSIS

 Symptoms  Signs  Non-specific irritation  Upper lid laxity  Foreign body sensation  Papillary conjunctivitis  Te a r i n g  Mucoid discharge  Mucoid discharge  PEK  Dryness  Redness 

TREATMENT

 Medical

 Surgical

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MEDICAL TREATMENT

 Weight loss  Treatment of OSAHS  Lid shield at night*  Lid taping  Nocturnal lubrication  To p i c a l s t e ro i d s  Topical antihistamines http://www.attorneyone.com/law-news/refresh-lacri-lube  Treatment of any blepharitis/meibomianitis

SURGICAL MANAGEMENT

 Full-thickness wedge excisions

 Lateral tarsal strip procedure

 Lateral canthal tendon plication

 Lateral tarsorrhaphy

http://0- www.sciencedirect.com.libcat.ferris.edu/science/article/pii/S 1389945705001607

CASE REPORT

CC/HPI PERTINENT HISTORY  68 year old WM  + OSAHS  Dryness, FBS  Dx about 8 months prior  OS>OD  (+) CPAP use  Seasonal allergies  About 6 months  No other systemic condition  Not using any lubrication reported  History of allergies  Multivitamin

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CASE REPORT

ENTERING DATA DIAGNOSIS/TREATMENT  VA: 20/20 OU  1. FES  : PERRLA  2. Dermatochalasis  EOM: FROM, OU  3. Blepharitis  IOP: 13/12  4.  Marked lid laxity w/significant dermatochalasis  1+ superior papillary reaction,  Treatment trace inferior papillary reaction  Eyelid taping  Blepharitis  Refresh P.M.  Trace SPK, OU  Monitor in 1 month  Posterior segment: unremarkable

CASE REPORT: FOLLOW UP

CC/HPI TREATMENT  Little to no improvement  Started patient on Lotemax BID  Reports taping lids qhs  Recommended referral to  Uses Refresh P.M. qhs oculoplastics surgeon  Dryness, FBS still present  Recommended  Consider long term use of anti- histamine

REFERENCES  Karger RA, White WA, Park W-C, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Am Acad of Ophth. 2006;113(9):1669-74  Das A, Radhakrishnan A. Teaching neruoimages: floppy eyelids in obstructive sleep apnea syndrome. Resident & Fellow Section. 2007;77:1-2.  Muniesa M, Sanchez-de-la-Torre M, Huerva V, et al. Floppy eyelid syndrome as an indicator of the presence of glauoma in patients with obstructive sleep apnea. J Glaucoma. 2014;23:81-85.  Leibovitch I, Dinesh S. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med. 2006;7:117-22.  Ezra D, Beaconsfield M, Collin R. Floppy eyelid syndrome: stretching the limits. Surv of Ophth. 2010;55:35-46  Miyamoto C, Santa L, Roisman, et al. Floppy eyelid syndrome: review. Arq Bras Oftalmol. 2011;74(1):64-6.  Royo M, Ribot A, Sanchez-de-la-Torre M, et al. Corneal biomechanical properties in floppy eyelid syndrome. Cornea. 2015;34(5);521-24.  Huevra V, Muniesa M, Ascaso F. Floppy eyelid syndrome in obstructive sleep apnea syndrome. Sleep Med. 2014;15:724-27.

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QUESTIONS

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