Continuous Positive Airway Pressure Effect on Progression of Retinal Disease in Patients with Sleep Apnea and Nonproliferative Diabetic Retinopathy: A Randomized Clinical Trial.

Rationale: Obstructive sleep apnea (OSA) is associated with impaired glycemic control and a higher risk of vascular complications, such as diabetic retinopathy. However, the effect of apnea-hypopnea suppression on retinal disease progression is unclear. Objectives: To evaluate the efficacy and safety of continuous positive airway pressure (CPAP) for the reduction of retinal lesions in patients with non-proliferative diabetic retinopathy (NPDR) and OSA. Methods: This open-label, parallel-group, randomized controlled trial was conducted between October 2016 and February 2020 at a university hospital in Spain. The date of final follow-up was March 2, 2021. Eighty-three patients with OSA and mild to moderate NPDR receiving stable treatment were randomized to receive CPAP and usual care (43 patients with 79 available eyes) or usual care alone (40 patients with 67 available eyes) for 52 weeks. The primary outcomes were the change in the percentage of eyes with retinal exudates and the number of retinal microhemorrhages from baseline to week 52. We also assessed the effects of both interventions on retinal thickness by means of optical coherence tomography, serum concentrations of glycated hemoglobin, blood pressure, lipid concentrations, sleepiness, and quality of life. Results: Fifty-two weeks of CPAP treatment was associated with reductions from baseline in the percentage of eyes with hard exudates (overall difference, -21.7%; P = 0.035) and in optical coherence tomography indices of retinal edema, including central subfield thickness and cube volume. However, in patients who met prespecified criteria for CPAP adherence, treatment was also associated with a higher number of retinal microhemorrhages at 52 weeks (intergroup adjusted difference, 6.0 [95% confidence interval, 0.6-11.5]; P = 0.029), which was directly related to prescribed pressure levels. CPAP treatment also improved glycemic control, sleepiness, and general health-related quality of life. Conclusions: In patients with OSA and NPDR, long-term CPAP treatment in addition to usual care may result in slower progression of retinal disease, although it could also induce an increase in retinal microhemorrhages. Clinical trial registered with www.clinicaltrials.gov (NCT02874313).

Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms.

Eye diseases are an important group of increasingly prevalent disorders that contribute very significantly to disability and represent a considerable health burden. Some data suggest that several of these diseases may be associated with sleep-disordered breathing, mainly obstructive sleep apnea (OSA), due to intermediate mechanisms, such as intermittent hypoxia or sleep fragmentation. The aims of this systematic review were to identify and critically evaluate the current evidence supporting the existence of a possible relationship between OSA and the more relevant eye diseases as well as to evaluate the potential pathogenic mechanisms. There is a body of largely low-level evidence for the association of OSA with glaucoma, nonarteritic ischemic optic neuropathy, central serous chorioretinopathy, and diabetic retinopathy. Meta-analysis of available case-control studies shows that OSA increases the risk of glaucoma (pooled odds ratio: 1.50; 95% confidence interval: 1.25 to 1.80; P < .001), nonarteritic ischemic optic neuropathy (3.62; 1.94 to 6.76; P < .001), and diabetic retinopathy (1.57; 1.09 to 2.27; P = .02). Moreover, several pathogenic pathways have been identified, mainly related to hypoxic damage, mechanical stress, systemic inflammation, oxidative stress, sympathetic tone, and endothelial dysfunction. In contrast, information about the effect of apnea-hypopnea suppression on the development and progression of eye damage is either nonexistent or of a very low level of evidence. In conclusion, OSA has emerged as an additional potential risk factor for many eye diseases, although their link is weak and contradictory, so further examination is required. CITATION: García-Sánchez A, Villalaín I, Asencio M, García J, García-Rio F. Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms. J Clin Sleep Med. 2022;18(1):265-278.

RECURRENT ACUTE RETINAL PIGMENT EPITHELIITIS: SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES.

PURPOSE: To describe an atypical case of acute retinal pigment epitheliitis including spectral domain optical coherence tomography (OCT) and OCT angiography features. METHODS: We report a 41-year-old woman with 3 episodes of acute retinal pigment epitheliitis over a 3-year period. Spectral domain OCT and OCT angiography images were acquired with Cirrus 5,000 spectral domain OCT. RESULTS: Although acute retinal pigment epitheliitis is described as a benign, self-limited pathology, as this case shows, recurrences are possible. OCT angiography shows a choriocapillaris alteration and further recovery during the acute episodes. CONCLUSION: Acute retinal pigment epitheliitis can present as a recurrent disease.

OCT Angiography: Imaging of Choroidal and Retinal Tumors.

OBJECTIVE: Optical coherence tomography angiography (OCTA) is a new, noninvasive imaging modality used to assess the vasculature in chorioretinal disease. The purpose of this study was to describe OCTA findings in several chorioretinal tumors, specifically melanocytic tumors. We correlate these findings with clinical risk factors (RFs) for growth. STUDY DESIGN: This was a cross-sectional, comparative, observational study. SUBJECTS: We compiled a total of 79 cases consisting of the following: 55 choroidal nevi, 11 choroidal melanomas, 5 choroidal hemangiomas, 3 astrocytic hamartomas, 2 choroidal lymphomas, 1 choroidal metastases, 1 combined hamartoma of the retina and retinal pigment epithelium (RPE), and 1 choroidal osteoma. METHODS: We performed OCTA of the 79 lesions to create images that were then analyzed by 3 different physicians. In addition to OCTA, we also used multi-imaging studies, including OCT, retinal color and autofluorescence fundus imaging, Doppler echography, and indocyanine/fluorescein angiography. The melanocytic lesions were divided into 6 different groups according on the number of clinical RFs present. We compared each group with the OCTA findings, seeking any correlation between OCTA findings and the number of RFs present. OUTCOME MEASURES: All layers of the OCTA were evaluated and described. In melanocytic lesions, 6 specific variables within the choriocapillaris layer were evaluated. We also studied the quality of the images, the presence of avascular areas within the lesion, heterogeneity of the choroidal plexus over the lesion, the presence of a neovascular membrane associated with the lesion, the definition of the lesion's borders, and the presence of a hyperreflective ring surrounding the lesion. RESULTS: Satisfactory imaging was obtained in 82.7% of the cases. Concordance κ indexes between the observers were satisfactory (0.768-0.958). For melanocytic lesions, the images of choroidal nevi were described mainly as heterogenic (61.4%) and hyperreflective (81.8%). Choroidal melanoma was mainly described as isoreflective or hyporeflective (62.5%) and associated with a hyperreflective ring (62.5%). The presence of a hyporeflective plexus within the tumor (P = 0.002) and the presence of a hyperreflective ring surrounding the lesion (P = 0.001) were associated with lesions with more RFs. General descriptive OCTA findings are made for nonmelanocytic tumors. CONCLUSION: OCTA is a very promising new technology that can be used in the study of posterior segment ocular tumors. When studying melanocytic tumors, the presence of a hyporeflective plexus or hyperreflective ring (in the choriocapillaris layer) surrounding the tumor is associated with a higher risk of malignancy. Larger studies are needed to corroborate these findings. However, we hope that these data can encourage more regular screening for those detected to be at high risk and, hence, reduce the risk of malignancies detected at a late stage.

Structural and Functional Outcomes in Chronic Central Serous Chorioretinopathy Treated with Photodynamic Therapy.

PURPOSE: To study the retinal pigment epithelium (RPE) and retinal alterations in chronic central serous chorioretinopathy treated with photodynamic therapy, and its correlation with functional parameters such as best-corrected visual acuity (BCVA) and contrast sensitivity (CS). METHODS: Retrospective, noncomparative, consecutive evaluation by optical coherence tomography and its correlation with BCVA and CS in 31 eyes of 26 patients. RESULTS: In all affected patients, 88.5% were male with a mean age of 42.9 years. The right eye was involved in 64.5% of cases, bilateral in 19% and 73.9% were hyperopic (spherical refraction between 0 and +5.0 diopters). Of these cases, 51.5% had peri-RPE abnormalities, 17.3% hyperreflective substances at RPE, 19.4% RPE atrophy, 55.3% foveolar atrophy, 3.1% pigment epithelial detachment, 5.2% subretinal fluid persistence, 8.3% fibrin deposits, 68.4% photoreceptor inner and outer segment line interruption and 31.1% external limiting membrane interruption. CONCLUSIONS: Time evolution and number of outbreaks were related to the decrease in foveal and chorodial thickness and in those with worse BCVA and CS. RPE abnormalities and atrophy were related to the age of onset of symptoms. Photoreceptor elongation has been correlated with poor BCVA and inner and outer segment line destructuring and interruption with poor CS.

Uveal melanoma in a 19-month-old child.

Uveal melanoma is extremely rare in children. Its clinical and histopathological features have been reported to be similar to those observed in adults. The tumor usually presents as a sessile or dome-shaped mass with secondary nonrhegmatogenous retinal detachment. We report a 19-month-old boy with a choroidal melanoma presenting as hemorrhagic retinal detachment and buphthalmos. The eye was enucleated, but the child subsequently died from systemic metastases.

Nasolacrimal stents for the treatment of epiphora: technical problems and long-term results.

PURPOSE: To evaluate the long-term effectiveness of nasolacrimal stents for the treatment of obstructive epiphora, and the complications related to the procedure. METHODS: This study is a non-randomized prospective clinical trial. Eighty-five patients underwent fluoroscopally-guided placement of polyurethane stent in 86 lacrimal systems for the treatment of severe idiopathic obstructive epiphora. The sites of obstruction were: sac-duct junction (n = 65), sac (n = 10), and nasolacrimal duct (n = 11). The procedure was performed in an outpatient basis under local anesthesia. Patients were followed for a mean of 24 months (1-84) with clinical examinations and/or dacryocystography. Clinical success was defined as symptoms resolution or improvement, and the patency of the lacrimal system to irrigation. RESULTS: Stent placement was technically successful in 76 (88.4%) eyes. Technical failures (11.6%) were caused by inability to pass the guide-wire through the lacrimal system. Immediate complications occurred in 19 (22%) eyes, were mild and included: self-limited epistaxis (7), mild palpebral hematoma (7), moderate pain (3), lacrimal puncta bleeding (1), palpebral emphysema (1), and false passage (1). Of the 76 inserted stents, 33 (43.4%) became occluded, and 43 (56.6%) remained patent after a mean of 24 months. Mean duration of stent patency was 38 months. Clinical success was achieved in 40 (52.6%) of the successfully implanted stents. CONCLUSIONS: The procedure is well tolerated and can be performed on an outpatient basis. Patency decreases with follow-up, and, in the long-term, the success rate is inferior to that achieved by external dacryocystorhynostomy. However, it many be considered as a valid alternative to surgery in selected patients.