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 Conjunctiva 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.