3/14/2016
SLEEP APNEA AND THE EYELIDS Sara Nonhof, O.D.
Floppy Eyelid Syndrome First described in 1981
Definition: • easily everted eyelids • chronic papillary conjunctivitis • 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/
1 3/14/2016
OCULAR ASSOCIATIONS
Eyelids
Cornea
Glaucoma
OCULAR ASSOCIATIONS: EYELIDS
Function: protect ocular surface
Become easily distorted and everted http://www.drvisionworld.com/demodex-infestation/ Other pathologies reported Ptosis Dermatochalasis Blepharochalasis Upper lid lash ptosis Entropion/Ectropion Blepharitis, 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
2 3/14/2016
OCULAR ASSOCIATIONS: CORNEA
Punctate epithelial keratopathy Most common finding Diffuse Typically only involves affected eye
Keratoconus 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
3 3/14/2016
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
4 3/14/2016
“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 Photophobia
TREATMENT
Medical
Surgical
5 3/14/2016
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
6 3/14/2016
CASE REPORT
ENTERING DATA DIAGNOSIS/TREATMENT VA: 20/20 OU 1. FES Pupils: PERRLA 2. Dermatochalasis EOM: FROM, OU 3. Blepharitis IOP: 13/12 4. Allergic conjunctivitis 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 blepharoplasty 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.
7 3/14/2016
QUESTIONS
8