Optometric Physician



Vol. 24, #15 •   Monday, April 10, 2023


Off the Cuff: Funny Sounding Name, Serious Implications

It is always interesting when associations emerge between specific clinical findings and a seemingly unrelated condition. One particular association that seems to pop up consistently involves the descriptively named floppy eyelid syndrome (FES) and sleep apnea. Many are likely familiar with this association, but I am often astounded by how common this finding is in daily practice. However, I should not be too surprised considering that it is estimated that 14-49% of middle-age men in the US and Europe have clinically significant sleep apnea.1 This is why any time I pull down on the lower lid or lift the upper during the course of an exam, and the lids evert with only the slightest effort or even double over on themselves, my mind immediately jumps to sleep apnea. This excessive lid laxity is the ocular hallmark of the disease, but it often goes undiagnosed. And as Dr. Steinhäuser has noted and written about previously, hemorrhages in the retinal periphery also appear to be a sign of sleep apnea, so it is not as though the condition is failing to make its presence known. What is perhaps most surprising about how often sleep apnea-associated FES flies under the radar is the fact that, despite its somewhat humorous sounding name, it is not an inconsequential disease.

From an ocular surface standpoint, it can cause significant disruption including recurrent corneal erosions, chronic papillary conjunctivitis with copious mucus production due to excessive mechanical friction as the loose lids rub against the ocular surface, dry eye caused by nocturnal exposure, and abrasions associated with spontaneous lid eversion that may occur during sleep. Even patients who are being treated with a CPAP or BiPAP are not out of the woods, as even the best of mask seals are often not perfect, and it is not unusual for these patients to have issues with nocturnal dryness due to the evaporative stress of air blowing over the ocular surface the entire night. However, even more concerning is the fact that sleep apnea has been associated with non-arteritic anterior ischemic optic neuropathy, as the repeated apneic episodes can lead to hypoperfusion of the optic nerve during sleep, as well as CRVO and BRVO. Yet even more dire are the potential systemic health implications, as untreated sleep apnea can increase the risk of heart attack, stroke, cardiac arrythmia, and even congestive heart failure.

So, every time I observe FES, I ask the patient if they have any issues sleeping—specifically if they often wake up feeling tired even though they got a full night of sleep, or if they know if they snore. Typically, I get one of two responses—either something along the lines of “Oh yeah, I have sleep apnea and I use a CPAP” or “I do feel tired all the time and my wife says my snoring shakes the house.” What is particularly interesting is that patients time and time again, for some reason, do not report having sleep apnea when giving their initial health history. They will report having high blood pressure or diabetes, but they rarely ever mention sleep apnea. This is a strange phenomenon that Dr. Steinhäuser has noticed as well. In cases where patients have all the symptoms of sleep apnea but have not been diagnosed, I always educate them on the risks associated with untreated sleep apnea and advise them to undergo a sleep study.

Also, it is worth noting it is not just the classic overweight, barrel-chested middle-age man who has sleep apnea, we also find it in thin, often elderly, women with low blood pressure, due to risks associated with hypotension. So, whenever you encounter an excessively floppy eyelid, ask the patient about the symptoms of sleep apnea, and you may be surprised by how many have the condition but did not mention it, or how many have it but have never been diagnosed. By noticing a floppy eyelid, you could end up ultimately saving someone’s vision, or even their life.

1. Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5):920-9.

Cory J. Lappin, OD, MS, FAAO


Want to share your perspective?
Write to Dr. Shannon L. Steinhäuser, OD, MS, FAAO at ssteinhauser@gmail.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.


Association of Diabetes, Fasting Glucose, and the Risk of Glaucoma: A Systematic Review and Meta-Analysis

Researchers designed this systematic review to summarize the diabetes-related glaucoma articles produced from 2011 to 2022. They further aimed to perform a meta-analysis to determine the vital association between these two parameters. Data sources such as PubMed, Medline, and Embase were used to find the relevant research. Reviews, case reports, and editorial letters were excluded. Article inspection was conducted by the main author who extracted the study title and abstract in the first screening by using keywords to find the eligible articles. Heterogeneity was accessed by using the Cochrane Q test and I2 test.

Ten studies were reported with 2,702,136 cases of diabetes. Out of these, 64,998 incidents of glaucoma were observed. The pooled prevalence of diabetic retinopathy was 11.7% associated with glaucoma. A significant I2 value was achieved (100%) with Cochran's Q of 183.6.

In conclusion, researchers found diabetes duration, elevated IOP, and fasting glucose levels were one of the leading risk factors for glaucoma. Fasting glucose levels and diabetes were also major contributors to elevated IOP levels.

SOURCE: A AlDarrab, O J Al Jarallah, H B Al Balawi. Association of diabetes, fasting glucose, and the risk of glaucoma: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2023;27(6):2419-27.



Differences in Retinal Image Quality Between Normal and Subclinical Keratoconus, and Association With Posterior Corneal Asymmetry

Sixty normal corneas were compared to 20 subclinical keratoconus (SKC) corneas to compare retinal image quality in subclinical keratoconus and normal eyes using a double-pass aberrometer, and to correlate SKC with posterior surface deformation. Retinal image quality was assessed using a double-pass system in all the eyes. The objective scatter index (OSI) modulation transfer function (MTF) cutoff, Strehl ratio (SR), and predicted visual acuity (PVA) values at 100%, 20%, and 9% were calculated and compared between the groups. Posterior corneal asymmetry was measured using a combined Placido Dual Scheimpflug Analyzer, and correlations were tested with all optical quality parameters.

A significant decrease in optical quality parameters was observed in SKC eyes compared with that in normal eyes. SKC eyes expressed greater scattering (OSI = 0.66 ± 0.36 vs. 0.47 ± 0.26) and reduced contrast images (MTF and SR) than normal eyes, with 38.82 ± 9.4 and 0.22 ± 0.04, and 44.35 ± 7.1 and 0.24 ± 0.04, respectively. The reduction in the image contrast parameters (MTF and SR) was strongly correlated to the level of posterior corneal asymmetry in SKC. The greater the posterior asymmetry, the more affected was the image contrast, with r=-0.63 and -0.59, respectively for MTF and SR.

Retinal image quality was significantly more affected in eyes with subclinical keratoconus than in normal eyes. The reduction in optical quality observed in subclinical keratoconus was strongly associated with the increased asymmetry of the posterior cornea.

SOURCE: Smadja D, Krauthammer M, Wajnsztajn D, et al. Differences in retinal images quality between normal and subclinical keratoconus and its association to posterior corneal asymmetry. Eur J Ophthalmol. 2023 Apr 3. [Epub ahead of print].

Evaluation of Eyelid, Angle, and Anterior Segment Parameters Using Scheimpflug Camera and Topography System in Obstructive Sleep Apnea Syndrome

The purpose of the study was to investigate the eyelid hyperlaxity, anterior segment, and corneal topographic parameters in patients with obstructive sleep apnea syndrome (OSAS) using a Scheimpflug camera and topography system. In this prospective and cross-sectional clinical study, 32 eyes of 32 patients with OSAS and 32 eyes of 32 healthy subjects were evaluated. The participants with OSAS were selected from those with an apnea-hypopnea index ≥15. The minimum corneal thickness (ThkMin), apical corneal thickness (ACT), central corneal thickness (CCT), pupillary diameter (PD), aqueous depth (AD), aqueous volume (AV), anterior chamber angle (ACA), horizontal anterior chamber diameter (HACD), corneal volume (CV), simulated K readings (sim-K), front and back corneal keratometric values at 3mm, RMS/A values, highest point of ectasia on the anterior and posterior corneal surface (KVf, KVb), symmetry indices and keratoconus measurements were taken by combined Scheimpflug-Placido corneal topography and compared with healthy subjects. Upper eyelid hyperlaxity (UEH) and floppy eyelid syndrome were also evaluated.

Investigators reported no statistically significant difference between groups in terms of age, gender, PD, ACT, CV, HACD, simK readings, front and back keratometric values, RMS/A-KVf and KVb values, symmetry indices, and keratoconus measurements. ThkMin, CCT, AD, AV, and ACA values were significantly higher in OSAS group compared to controls. UEH was detected in two cases in the control group (6.3%) and in 13 cases in the OSAS group (40.6%), and the difference was significant (p<0.001).

Investigators wrote that the anterior chamber depth, ACA, AV, CCT, and UEH increased in OSAS. They added that these ocular morphological changes occurring in OSAS may explain why OSAS patients are prone to normotensive glaucoma.

SOURCE: Isik I, Yazgan S, Erboy F, et al. Evaluation of eyelid, angle, and anterior segment parameters using scheimpflug camera and topography system in obstructive sleep apnea syndrome. Beyoglu Eye J. 2023 Mar 1;8(1):5-13.




Industry News

Florida Bill Amended to Preserve ODs’ Right to Use Physician Title

At least three states (Florida, Connecticut, and Texas) introduced legislation this year that would prohibit certain healthcare providers—potentially including optometrists—from advertising or referring to themselves as “physicians” in medical settings if the term is not defined in their respective practice acts. On March 15, Florida’s anti-optometry bill, SB 230, unanimously passed the state Senate 37-0. The bill awaits a hearing in the House of Representatives and has been filed as HB 583. After significant pushback from optometrists and advocates, including the Florida Optometric Association, an amendment was made to the bill March 31, so it now states: “An optometrist licensed under chapter 463 [Florida’s practice act for optometrists] may use the following titles and abbreviations as applicable to his or her license, specialty and certification: ‘doctor of optometry,’ ‘optometric physician’ and other titles or abbreviations authorized under his or her practice act.” If HB 583 passes the Florida House and is signed into law with the amendment, it will preserve the right of ODs to refer to themselves as optometric physicians—despite the term’s exclusion from the current practice act—if their medical license, specialty, or certification explicitly describes them as such. Read more.

TearRestore Dry Eye Solutions Now Available Nationwide at Target

TearRestore, offering a suite of FDA-cleared products supporting dry eye relief, announced its Thermal Mask and Eyelid Wipes will now be available at Target stores nationwide and at Target.com. Read more.


• Euclid Vision welcomed Jon R. Hudson, ABOC, NCLEC, as account executive for Texas, and central and southern U.S. territories. Read more.
• Thea welcomed John Ruffino as marketing team member of TPI. Ruffino joins as the first associate director of digital marketing.













Journal Reviews Editor:
Katherine M. Mastrota, MS, OD, EMBA, FAAO

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