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

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.