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Most people cherish the time they can lay in bed each night, close their eyes and go to sleep, but millions of Americans suffer from sleep-related disorders.  These sleep-related disorders can have serious implications for your health, but can problems with sleep affect ocular comfort and function?

Obstructive sleep apnea (OSA) affects 9% of women and 24% of men between the ages of 30 and 60 years old ¹. The condition is characterized by repeated episodes of airway obstruction during sleep that impede or stop breathing ^2,3. Major risk factors include male gender, age and obesity ³.  OSA can result in many significant consequences including: daytime sleepiness and fatigue, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction and cor pulmonale ². More recently, studies are linking OSA to a variety of ocular disorders that if left untreated, can lead to vision loss.

Floppy Eyelid Syndrome (FES) is a condition that has been closely associated with OSA ^3,4. It is characterized by easy or spontaneous eversion of the upper eyelids, most often occurring during sleep.  As the eyelids’ delicate mucosa is repeatedly exposed, patients develop a chronic conjunctivitis, inflammation of the membrane lining the eyelids. As with OSA, patients may not even realize this occurrence and only begin to complain when they become symptomatic. 

The typical FES patient will present with unexplained chronic red and irritated eye, often worse in the morning and associated with mucous discharge.  The symptomatic eye tends to correspond with the side the patient sleeps on, but both eyes may be affected when the patient does not have a preferred side or sleeps face down ^4,5. FES shares a similar patient profile to OSA: middle-aged or older, obese male. 

Along with the typical papillary conjunctivitis, FES is associated with a variety of other ocular pathologies. The lids may be structurally affected resulting in ptosis (droopiness of the upper lids), lash ptosis (down-turning of the upper eyelashes), upper lid entropion (turning in of the upper lid margin), lower lid ectropion (turning out of the lower lid margin) and blepharochalasis (inflammation of the eyelids causing repeated episodes of lid edema) ^4,5.

The surface of the eye essential to clear vision (the cornea) is also commonly affected in FES patients. Reported associations include punctuate keratopathy, corneal vascularization, corneal ulcers and scars, infectious keratitis and keratoconus (a progressive disease characterized by corneal thinning) ^4,5.  Tear film abnormalities and meibomian gland dysfunction may also occur ⁴.

Treatment is based on symptomatic relief through topical lubricants and protection of the eyelids at night with eye shields.  Weight loss is also a common part of treatment plans ⁵. Several patients with FES and OSA have been described to have shown significant improvement and even resolution of ocular symptoms when treated with continuous positive airway pressure, a common treatment for OSA ⁶.  When medical treatment is not sufficient, surgical techniques are employed to repair lid structure and address eyelid laxity ^4,5. 

            Sleep-disordered breathing, such as OSA, can also be an important risk factor in oculovascular diseases ³. Direct exposure to hypoxia and hypercapnia may cause damage to the optic nerve head ³.  Vascular changes and fluctuating O₂ and CO₂ levels may damage the autoregulatory mechanisms of optic nerve perfusion leaving it more vulnerable to ischemic events ³. In particular there have been reports of associations of OSA with glaucoma, non-arteritic anterior ischemic optic neuropathy and papilledema ³. Left untreated, any of these diseases can result in severe, permanent loss of vision.

            Glaucoma is a type of optic neuropathy that results in slow, progressive loss of vision and is often associated with elevated intraocular pressure (IOP). Several studies found a higher prevalence of glaucoma in patients with OSA than in normals ^7,8. Karakucuk et al. also found a positive correlation between IOP and respiratory disturbance index (# of apneas in an hour).  Other studies demonstrated greater self-reported symptoms of sleep disturbance in both patients with primary open angle glaucoma and normal tension glaucoma than in the normal groups ^9,10.

            Non-arteritic anterior ischemic optic neuropathy (NAION) can cause severe vision loss due to hypoperfusion of the optic nerve. In several prospective studies a high prevalence of OSA in patients with NAION have been reported (71-89%) ^11,12. Palombi et al. reported the rate of sleep apnea as a risk factor for NAION was 1.5-2 times greater than hypertension and diabetes ¹². This strong association between OSA and NAION suggests that OSA is an important risk factor for NAION.

            Papilledema is the swelling of the optic nerve head due to raised intracranial pressures. Extended periods of swelling can lead to permanent damage of the nerve and visual function. A study by Purvin et al. looked at 4 OSA patients with elevated ICP and papilledema ¹³. When their sleeping disorder was treated, the papilledema resolved ¹³.