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Editors Selection IGR 14-2

Glaucoma and Systemic Diseases: Sleep Apnea and Glaucoma

Comment by Steve Mansberger & Erick Rivera on:

107255 Long-term effects of obstructive sleep apnea and its treatment on open-angle glaucoma: a big-data cohort study, Lee TE; Kim JS; Yeom SW; Yeom SW et al., Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 2023; 19: 339-346

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This study includes over 12,000 subjects from a health services database from Korea to determine whether obstructive sleep apnea (OSA) and incident glaucoma have an association. The Study groups were defined as subjects with an OSA diagnosis within a two-year period and are matched to a Control group based on gender, residential area, economic status and other health conditions. They queried the database over the subsequent ten years for incident glaucoma, and excluded subjects that received a diagnosis of OSA during the follow-up period. Patients with OSA have 42% increase in risk (Hazard Ratio (HR) of 1.42) for developing OAG compared to non-OSA patients. In only a two-year period, treatment of OSA, either OSA surgery or CPAP treatment, decreased the risk of developing OAG (HR 0.71, HR 0.06).

Another issue is that the study excluded those that developed OSA, and would be more likely to create attrition from the control group and increase the likelihood of an association in the Study group. This might magnify the treatment of OSA

The study strengths are its large sample size and adjustment for multiple factors associated with glaucoma and sleep apnea. However, there are a number of possible weakness. The CPAP data and treatment was only collected for two years. It is surprising that this had such a large effect when only available for two years and available at the end of the study. Another issue is that the study excluded those that developed OSA, and would be more likely to create attrition from the control group and increase the likelihood of an association in the Study group. This might magnify the treatment of OSA. It would be valuable to understand how including them would influence the results and consider adjustment for follow-up time. The study does not define glaucoma and a selected small chart review to validate the diagnosis of glaucoma would be valuable. Finally, it would be important to state and control for sleep testing since some patients with glaucoma may have been referred for sleep testing and vice versa. Did the patients undergo any other confounding treatment for their sleep apnea such as weight loss?

While the benefits to glaucoma of treating OSA is still controversial, it is important to refer patients with suspected sleep apnea for testing because treatment of sleep apnea has large health benefits for other health conditions

We congratulate the authors on this longitudinal study. While the benefits to glaucoma of treating OSA is still controversial, it is important to refer patients with suspected sleep apnea for testing because treatment of sleep apnea has large health benefits for other health conditions. I refer patients for sleep testing if they are falling asleep during their visual field testing; have snoring and become apneic during their eye surgery; or give a history of sleep disturbances.

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