A Putative Relation between Obstructive Sleep Apnea and Diabetic Macular Edema Associated with Optic Nerve Fiber Layer Infarcts

Abstract

Abstract:Purpose: To describe a possible relationship in obese diabetics between obstructive sleep apnea syndrome (OSAS) and ischemic retinopathy with diffuse macular edema.Design: Prospective, observational case series. Methods:Obese diabetics (n=22) in a retina clinic who admitted to symptoms of sleep apnea on survey were compared with a cohort of 22 similarly obese diabetic patients.Complete ocular examination, fundus photography, fluorescein angiography,overnight polysomnography, blood pressure measurement, and blood testing for HgA1C, CBC, lipid profile, ESR, c reactive protein, BUN, creatinine and proteinuria were evaluated.Results: Among the 22 obese diabetics of apnea cohort who underwent polysomnography, 16 demonstrated severe and 6 moderate OSAS. An average of 44.6+21.9 apneic or hypopneic events per hour were recorded during sleep, lasting on average 23.3+5.9 seconds, resulting in oxygen desaturation of 73.5+9.5%. The retinopathy observed in the apnea cohort manifested multiple nerve-fiber-layer infarcts, at least 3 in each eye in all cases, and more than 6 infarcts in most eyes.. Among the cohort without sleep apnea, rare nerve fiber layer infarcts were observed, and the retinal microvascular leakage and macular edema was more focal and resolved with grid laser. Among the measured systemic factors, none showed a statistical difference between apneic and non-apneic cohorts. Conclusions:In obese diabetics, obstructive sleep apnea appears to be associated with retinopathy of more aggressive course, manifesting multiple nerve-fiber-layer infarction and diffuse macular edema. Physicians should consider evaluating obese diabetics who have snoring, fragmented sleep patterns, daytime somnolence, hypertension or manifesting accelerated course of retinopathy similar to the patients described.

Diabetic Retinopathy–An Underdiagnosed and Undertreated Inflammatory, Neuro-Vascular Complication of Diabetes

“…Furthermore, impaired antioxidant defense systems including reduced enzymes such as catalase and glutathione peroxidase and superoxide dismutase, also lead to generation of retinal ROS/RNS that are exacerbated by variations in tissue exposure to glucose (52,53). Considering these conditions, it is not surprising that sleep apnea, with hypoxic episodes that result in retinal vessel dilation and hyperperfusion but are followed by reactive acute hypertensive reprise, are associated with severe exacerbation in the prevalence of diabetic retinopathy (54,55).…”

Effect of obstructive sleep apnoea on diabetic retinopathy and maculopathy: a systematic review and meta‐analysis

“…These studies, and four of the six studies that reported non‐adjusted ORs, reported no significant association between OSA and DR . Only two small studies from the USA ( n = 142) , in which no adjustments for potential confounders were made, reported significant associations; however, these unadjusted models were likely to be exposed to multiple confounders such as gender and BMI, therefore, overall, there was no convincing evidence that OSA was associated with DR in their Type 2 diabetes population.…”

“…The definition of DR was variable, and in six studies no clear definition was provided . Definitions included use of diagnosed DR through the English National Screening Program for Diabetic Retinopathy , or from medical records .…”

“…Eight studies ( n = 1134) reported the effect of OSA on overall DR ; only two ( n = 173) of which used multiple logistic regression analyses to adjust for confounders (Table ). These studies, and four of the six studies that reported non‐adjusted ORs, reported no significant association between OSA and DR .…”

“…Five studies examined the association between OSA and retinopathy scores as well as advanced DR . Two studies ( n = 149, only male participants) reported a significant association between OSA and total retinopathy scores using adjusted models .…”