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Editors Selection IGR 11-3

Risk Factors: Sleep apnea and glaucoma prevalence

Comment by Augusto Azuara Blanco on:

21811 Prevalence of glaucoma in patients with obstructive sleep apnoea: A cross-sectional case-series, Bendel RE; Kaplan J; Heckman M et al., Eye, 2008; 22: 1105-1109

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Bendel et al. (1148) report a very high prevalence of glaucoma (27%) in a series of patients with obstructive sleep apnea (OSA). Although the association between sleep apnea and glaucoma has been suggested before, the very high prevalence reported in this study is remarkable. There is other striking data: e.g., patients with glaucoma have an average IOP of 16 mmHg, similar to non-glaucomatous patients; body mass index or apnoea plus hypopnoea were not associated with glaucoma prevalence. I would highlight some potential flaws in the methods that would need to be clarified: first, regarding the cohort of patients with OSA: how many have been referred from an Ophthalmology Department? E.g., if ophthalmologists treating patients with glaucoma tend to refer the obese ones to rule out OSA the sample would be biased. The inclusion criteria are not specific. It is likely the 'glaucoma group' has included patients without glaucoma: not all patients with diffuse narrowing of the disc rim OR diffuse abnormalities of the retinal nerve fiber layer have glaucoma, OR c/d ratio greater than 0.7 have glaucoma. Furthermore, most patients with peripapillary atrophy OR generalized depression of the visual field with MD loss greater than 5 dB will not have glaucoma, but would have been categorized as glaucomatous in this study. The evidence would be more convincing if the authors had reported how many patients had early, moderate and severe glaucoma, and if a second masked investigator had agreed with the diagnosis of glaucoma.

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