3/14/2016 SLEEP APNEA AND THE EYELIDS PATHOGENESIS. Floppy Eyelid Syndrome. Sara Nonhof, O.D. Mechanical theory. Decreased tarsal elastin.

Transcription

1 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: PATHOGENESIS Mechanical theory Decreased tarsal elastin Lid laxity Tear film abnormalities/meibomianitis Chronic inflammation Alterations in collagen 1

2 OCULAR ASSOCIATIONS Eyelids Conjunctiva Cornea Glaucoma OCULAR ASSOCIATIONS: EYELIDS Function: protect ocular surface Become easily distorted and everted Other pathologies reported Ptosis Dermatochalasis Blepharochalasis Upper lid lash ptosis Entropion/Ectropion Blepharitis, Meibomianitis, Demodex OCULAR ASSOCIATIONS: CONJUNCTIVA Chronic papillary conjunctivitis Hallmark sign Epithelial and stromal changes are non-specific May delay in diagnosis 2

3 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 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 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

4 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 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

5 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 Waller EA, Bendel RE, Kaplan J. Sleep disorders and the eye. May Clin Proc. 2008;83: DIAGNOSIS Symptoms Non-specific irritation Foreign body sensation Tearing Mucoid discharge Dryness Redness Photophobia Signs Upper lid laxity Papillary conjunctivitis Mucoid discharge PEK TREATMENT Medical Surgical 5

6 MEDICAL TREATMENT Weight loss Treatment of OSAHS Lid shield at night* Lid taping Nocturnal lubrication Topical steroids Topical antihistamines Treatment of any blepharitis/meibomianitis SURGICAL MANAGEMENT Full-thickness wedge excisions Lateral tarsal strip procedure Lateral canthal tendon plication Lateral tarsorrhaphy CASE REPORT CC/HPI 68 year old WM Dryness, FBS OS>OD About 6 months Not using any lubrication History of allergies PERTINENT HISTORY + OSAHS Dx about 8 months prior (+) CPAP use Seasonal allergies No other systemic condition reported Multivitamin 6

7 CASE REPORT ENTERING DATA VA: 20/20 OU Pupils: PERRLA EOM: FROM, OU IOP: 13/12 Marked lid laxity w/significant dermatochalasis 1+ superior papillary reaction, trace inferior papillary reaction Blepharitis Trace SPK, OU Posterior segment: unremarkable DIAGNOSIS/TREATMENT 1. FES 2. Dermatochalasis 3. Blepharitis 4. Allergic conjunctivitis Treatment Eyelid taping Refresh P.M. Monitor in 1 month CASE REPORT: FOLLOW UP CC/HPI Little to no improvement Reports taping lids qhs Uses Refresh P.M. qhs Dryness, FBS still present TREATMENT Started patient on Lotemax BID Recommended referral to oculoplastics surgeon Recommended blepharoplasty Consider long term use of antihistamine 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): 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: Leibovitch I, Dinesh S. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med. 2006;7: 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); Huevra V, Muniesa M, Ascaso F. Floppy eyelid syndrome in obstructive sleep apnea syndrome. Sleep Med. 2014;15:

8 QUESTIONS 8