Off the Cuff: Sleep Apnea Screening in Ultrawidefield Retinal Imaging

At the end of 2021, I completed a master’s degree in clinical vision research. My initial research project comparing responses to nitric oxide donating glaucoma medications to serum nitric oxide levels in glaucoma patients had just gotten university IRB approval when COVID emerged. What started out as a delay eventually derailed that project all together. The dean of the program approved a report of a finding I had been monitoring in our practice since first hearing about it— the association of isolated far temporal retinal hemorrhages seen on ultrawidefield images with sleep apnea.

I can't take credit for this observation. In late 2018 I was at an AZOA meeting and in the Optos hospitality suite. Dr. John Markham from Prescott, AZ, and I were watching a demo of the Daytona model Optos when he asked me if I had one. I said I did. That's when he asked me if I had ever seen hemorrhages in the far periphery with none anywhere else. I had. He asked me what I thought those were from. I told him I wasn't entirely sure but assumed they may be blood pressure related. That's when he told me he'd been sending those patients out for sleep studies, and they were coming back positive for sleep apnea. I was intrigued. The next time I saw isolated hemorrhages in clinic, after asking, the patient already had a diagnosis of sleep apnea that he hadn't disclosed. This happened a few times. With patients who weren't diagnosed, I asked if they ever woke up in the morning tired or with headaches, or ever woke up gasping. If they answered yes, I'd send a note to their primary care physician requesting a sleep study. I was surprised at the number of patients returning with positive—often severe—sleep apnea diagnoses. I collected a couple years of data to evaluate when I had to shift gears for my master’s thesis and actually analyze it.

Researching and writing the background on sleep apnea was incredibly eye-opening. What I thought was merely snoring was so much more detrimental to a patient's systemic, mental, and ocular health. Sleep apnea is associated with heart disease, stroke, diabetes, depression, anxiety, and substance abuse. I knew about its association with glaucoma and floppy eyelid syndrome, but learned it's also associated with keratoconus, ischemic optic neuropathy, retinal vascular occlusive disorders, central serous, ectropion, and corneal erosions.

It's estimated that 20% of US adults suffer from sleep apnea, with an estimated 90% of those undiagnosed. If you have a retinal camera that images beyond the vortex veins, watch for these isolated hemorrhages and ask the questions. Something as simple as a screening ultrawidefield retinal photo has the potential to quickly and simply aid in finding these undiagnosed individuals and can be truly life-changing/-saving for these patients.

 

 

Shannon L. Steinhäuser, OD, MS, FAAO Chief Medical Editor ssteinhauser@gmail.com

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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.