Losing sleep over apnoea-glaucoma link Ocular Update Pippa Wysong Some studies suggest patients with Edward M Weaver MD, associate professor in Toronto primary open angle glaucoma have increased of otolaryngology and chief of sleep surgery rates of snoring, insomnia and excessive at the University of Washington was not OBSTRUCTIVE sleep apnoea (OSA) could daytime sleepiness (symptoms typical of particularly surprised by the study's findings. now be added to the list of suspected risk OSA).Yet, another study showed the greater He was not part of the study group, but factors for glaucoma and other optic nerve the number of apnoea symptoms OSA noted,“The possible effect of obstructive diseases, according to a recent review of the patients exhibited, the greater the increase in sleep apnoea on ocular disease is another topic in the Canadian Journal of Ophthalmology intraocular pressure (IOP), visual field loss interesting relationship that deserves further (CJO). But authors of the review say more variance, and glaucomatous optic disc investigation.There is growing evidence of study is needed to determine just how much changes. However, some studies didn't find a many effects of obstructive sleep apnoea on OSA contributes to eye disease. correlation between glaucoma and OSA, so other organ systems.” There are several features of OSA that definitive conclusions can't be made at this He said that the article provides a good could potentially affect the health of the support a possible link between OSA and time.There may also be other factors summary of preliminary data that are out optic nerve, according to Sukhjeet Dhillon eye disease. Some studies, however, found involved that could determine an OSA there that begin to support a relationship MSc, from Canada's University of Waterloo the association between the two somewhat patient's risk for eye disease. between OSA and specific ocular disorders, School of Optometry and colleagues. weak highlighting a need for high quality One suspect eye disease is papilledema. It and it hypothesises the pathophysiological “Sleep disordered breathing is a common studies. is caused by raised intracranial pressure and mechanisms. disorder that has been increasingly Yet, some studies are more compelling in has suspected links to both apnoea and OSA has effects on various physiological associated with eye diseases. It may make terms of possible links and mechanisms, and hypoventilation. Here, studies suggest hypoxia mechanisms that may affect organs and the eye vulnerable due to the effect of would suggest the area is worth pursuing as and hypercapnia caused by the breathing physiologic systems.Transient changes in hypoxia or it can involve pathways that lead a research direction, Graham Trope MD, a abnormalities characteristic of OSA raise blood pressure, intermittent hypoxia, and to impaired autoregulation of optic nerve professor of ophthalmology at the University intracranial pressure by causing vasodilation sympathetic activation are only some of the perfusion,” they note. of Toronto told EuroTimes. in the cerebral arteries.The authors found possible mechanisms through which OSA OSA is fairly common and occurs in an The review included studies investigating one small study where 33 per cent of could cause damage. estimated nine per cent of women and 24 OSA and various eye problems including patients with intracranial hypertension had From an ophthalmology perspective there per cent of men between the ages of 30 and glaucoma, nonarteritic anterior ischemic OSA and that their eye symptoms improved aren't enough data to support changes in the 60 years. But researchers say estimates are optic neuropathy, visual field defects, and after the OSA was treated. management of patients with eye disease and likely low, and that about 80 per cent to 95 papilledema. Although it has been suggested that OSA, but there are enough compelling data per cent of OSA cases remain undiagnosed. “The effects of OSA on body homeostasis intermittent apnoeic episodes lead to a to warrant further study, according to Dr OSA consists of repeated episodes of partial provide insight into how OSA can play a role deterioration of visual function and (or) Trope. However, he added if or complete obstruction of the airways in the pathogenesis of ocular dysfunction. ischemic damage to the optic nerve, one ophthalmologists have patients who are during sleep.Apnoea can lead to hypoxia, The immediate physiological effects of OSA cannot rule out the possibility that the middle-aged and overweight, and are OSA hypercapnea, blood pressure fluctuations, and involve hypoxia, hypercapnia, and inspiratory relation is mediated by additional factors, the suspects, it's worth referring them for a sleep possible changes in ocular haemodynamics, effort.These factors may directly impact the authors wrote. In other words, apnoea could assessment. the authors noted. functioning of the optic nerve or work in be one of several contributing factors to The researchers reviewed over 30 studies [email protected] concert to manifest as vascular sequelae,” vision problems in some patients, or possibly in the medical literature, some of which [email protected] the authors wrote. work in concert with other variables. Accurate diagnosis of preseptal and orbital cellulitis essential Devon Schuyler for inflammatory protopsis. If present, the ophthalmologist should send a culture to a has made it a much less frequent in Las Vegas patient should be evaluated for preseptal biology laboratory so that the infectious occurrence,” said Dr O'Brien.Treatment cellulitis; if absent, the patient should be agent can be identified and susceptibility can involves topical or systemic antibiotics, OPHTHALMOLOGISTS need to be able to evaluated for orbital cellulitis. Each of these be determined. Most cases are caused by sometimes with cefataxamine or ceftriaxone. differentiate between the various types of conditions has its own treatment plan. Staphylococcus aureus or Streptococcus preseptal and orbital cellulitis so that these pyogenes.Treatment involves incision and Orbital cellulitis patients can receive effective treatment. Preseptal cellulitis drainage of the preseptal suppuration, Proper diagnosis of the condition can be Orbital cellulitis refers to infection of the culture of the purulent material, and difficult, however. Preseptal cellulitis refers to infection of the soft tissue within the orbit, posterior to the intravenous nafcillin or oral cloxacillin. “Navigating the course of the patient who soft tissue of the eyelids and the periocular orbital septum. Dematoblepharitis and preseptal cellulitis, presents with inflammation of the eyelids can region anterior to the orbital septum.The “This is one of the true ophthalmic which also may be caused by Staphylococcus be quite challenging,” said Terrence O'Brien condition can lead to hyperaemia of the skin, emergencies.This is in the danger zone … aureus or Streptococcus pyogenes, should be MD, speaking at the annual AAO meeting. Dr distension of the eyelids, and conjunctival and it can lead to significant morbidity and treated with culture of skin lesions and O'Brien is a professor of ophthalmology at ecchymosis. even mortality,” said Dr O'Brien. intravenous nafcillin or oral cloxacillin. Bascom Palmer Eye Institute in Palm Beach, Preseptal cellulitis may occur in a post- He said that orbital cellulitis requires an Non-suppurative preseptal cellulitis in Florida. He recommended that physicians traumatic, suppurative form, or in aggressive approach to diagnosis and children is most often caused by zero in on the most distinctive signs, conjunction with dermatoblepharitis.There management, with immediate orbital imaging. Haemophilus influenzae type B or generate a differential diagnosis, consider is also a non-suppurative form that occurs in Predisposing factors in orbital cellulitis Streptococcus pneumoniae. other findings, and perform laboratory children less than six years old. include the proximity of the nasal sinuses “This used to be a common presentation, studies before initiating therapy. When faced with a case of post-traumatic but now, widespread use of the Hib vaccine The first step, he said, is to check the eye suppurative preseptal cellulitis, the Continued on page 31 30 Strabismus not just a paediatric problem Ocular Update Pippa Wysong they have convergence insufficiency.These doesn't see anything wrong and so refers the It may be beyond what you're happy with, but in Toronto patients are usually treated with eye patient to an ophthalmologist.Asking the it may not be something that is affecting your exercises to promote strengthening of the right questions can reveal the patient has patient's daily life,” Dr Kraft said. STRABISMUS, often considered a paediatric up-close efficiency of focussing. But, in some simply noticed a normal phenomenon – the He likens this sort of situation to a person problem, may not be referred for treatment adults, the exercises don't work.“The reason fact that objects beyond or in front of an prescribed blood pressure medication in adults because of a common is that the examiner has forgotten to check object you focus on appear as double. because their blood pressure went up during misperception that the surgery in adults is the patient's focussing range,” Dr Kraft said. Patients with trauma to the eye are a a scary movie. It doesn't give the whole purely cosmetic. But correcting problems If the near-vision focus is not normal, the whole other story.A common problem