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Editors Selection IGR 18-4

Quality of Life: Sleep quality disorders and glaucoma

Comment by Kaweh Mansouri on:

53244 Changes in the circadian rhythm in patients with primary glaucoma, Wang H; Zhang Y; Ding J et al., PLoS ONE, 2013; 8: e62841

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Wang et al. show that the prevalence of sleep disturbances is high in Chinese patients with POAG and PACG compared to age-matched controls. In this study, 140 glaucoma patients and 199 controls rated their sleep quality using the Pittsburgh Sleep Quality Index (PSQI) The PSQI is a widely used, selfrated questionnaire, which assesses the overall sleep quality over a one-month period. Its strength is a broad range of coverage in measuring several aspects of sleep quality and combining these into a global score. The authors further found a tendency for positive correlation between visual field impairment and PSQI score in POAG patients. Whether this is due to true correlation between glaucoma severity and sleep disturbance, or due to confounders such as depression, remains open.

In recent years, there has been growing evidence of continuous and large-scale degeneration of intrinsically photosensitive retinal ganglion cells (ipRGC) in glaucoma. These cells are responsible for the photic transduction to the circadian system and subsequent melatonin secretion. Melatonin is involved in the pathophysiology of circadian rhythm dysfunction, sleep disorders, depression and possibly in glaucoma. The relationship between glaucoma and melatonin seems to be bi-directional, as the death of ipRGCs can affect the rhythm of pineal melatonin production, which in turn, can affect the circadian system activity. This fact, as well as the retinal neuroprotective role of melatonin, suggests that melatonergic drugs may provide a potentially promising treatment supplement in glaucoma. Glaucoma affects the photic input and thereby circadian rhythms. Multidisciplinary treatment focusing on depression and normalization of circadian rhythms might be beneficial for glaucoma patients. Glaucoma may also be a useful model for studying interactions between the melatonergic, circadian, and mood systems.

Finally, this study is a timely reminder of the neglect that we bestow the 'sleeping giant', e.g., elevated nocturnal IOP. Thanks to laboratory work by Kwong et al.,¹ there is now good evidence to suggest that axonal injury is more related to dark phase than to light phase IOP elevation. Glaucoma damage literally happens when the ophthalmologist is sleeping.

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