Optometric Physician



Vol. 23, #47 •   Monday, December 12, 2022


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


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.





Effect of Surgical Face Mask Wearing on Tear Film in Women With a High Body Mass Index

Due to the COVID-19 pandemic, wearing a face mask has become an essential measure to reduce the rate of virus spreading. The aim of the study was to assess the effect of wearing a surgical face mask for a short period on the tear film parameters in subjects with a high body mass index (BMI).

Twenty-five females with a high BMI (31.4±5.5 kg/m2 ages 18 to 35 years (22.7±4.6 years) participated in the study. In addition, a control group consisting of 25 females (23±6.7 years) with a high BMI (29.9±4.1 kg/m2) participated in the study in which no mask was worn. The standardized patient evaluation of eye dryness (SPEED) questionnaire was completed first, followed by the phenol red thread (PRT) and tear ferning (TF) tests, before wearing the face mask. The subjects wore the face mask for 1 hour, and the measurements were performed again immediately after its removal. For the control group, the measurements were performed twice with one hour gap.

Significant differences were found between the SPEED scores and the PRT measurement before and after wearing the surgical face mask. The PRT scores improved after wearing the surgical face mask, while the dry eye symptoms detected by the SPEED questionnaire increased. On the other hand, no significant differences were found between the TF grades before and after wearing a surgical face mask. For the control group, no significant differences were found between the two scores from the SPEED questionnaire and the PRT, and TF tests.

Researchers wrote that wearing a surgical face mask for a short duration led to a change in volume and quality of tears as well as dry eye symptoms in women with a high BMI.

SOURCE: Alanazi MA, El-Hiti GA, Alotaibi R, et al. Effect of surgical face mask wearing on tear film in women with a high body mass index. PLoS One. 2022;17(11):e0277803.






Corneal Topography and Tomography Readings With Mask-Wear During the COVID-19 Pandemic

This study aimed to assess the effect of mask wear on corneal topography and tomography readings. Subjects underwent imaging with the Tomey TMS-4a topographer and the OCULUS Pentacam HR tomographer. Imaging was performed without a mask and then testing was repeated while wearing three different masks: Halyard Level 2, Halyard Level 3 and KN95. Measurements during mask wear were compared to measurements without a mask. The Kruskal-Wallis ANOVA grouped test was used to compare mean differences without vs. with mask wear on measurements. The chi-square test was used to compare frequency of differences between different masks and against-the-rule vs. with-the-rule astigmatism. The frequencies of clinically significant changes in axis of astigmatism, magnitude of astigmatism and mean keratometry values were calculated.

Fifty-two eyes were included in the study with a mean age of 34.71. Mask wear did not show statistically significant differences in mean topography and tomography measurements compared to without mask wear for all parameters. However, the majority, 53% (83/156) had a >10 degrees and 41% (64/156) had >15 degrees change in axis of astigmatism on topography when wearing a mask compared to no mask wear.

Mask wear did not result in statistically significant mean changes in keratometry readings on topography and tomography. However, axis of astigmatism varied >10 degrees in the majority of patients. Investigators wrote that axis determination should be interpreted with caution with respect to refractive surgery and/or toric intraocular lens planning in individuals whose measurements were obtained while wearing a mask.

SOURCE: Zein M, Wylegala A, Sripawadkul W, et al. Corneal topography and tomography readings with mask-wear during the COVID-19 pandemic. J Cataract Refract Surg. 2022; Nov 16. [Epub ahead of print].




Prevalence of Demodex folliculorum and Demodex brevis in Patients With Blepharitis and Chalazion

Demodex folliculorum and Demodex brevis are common ectoparasites on skin that also can lead to blepharitis and chalazion. The aim of our study is to determine the prevalence of Demodex spp. in eyelashes of patients diagnosed with chronic blepharitis and chalazion. This study included 330 patients diagnosed with chronic blepharitis, 70 patients diagnosed with chalazion and 130 volunteers without any ocular problems. Patient eyelashes were examined under a light microscope at magnifications of × 40, × 100 and × 400. Demodex spp. were determined.

Parasite prevalence was significantly higher in blepharitis (75.5%) and chalazion groups (70%) compared to the control group (16.2%). The prevalence of D. folliculorum in the blepharitis group and D. brevis in the chalazion group was found to be significantly higher compared to other groups. The average number of mites per eyelash was found to be significantly higher in patients with Demodex positive blepharitis and in chalazion patients than in the control group. It has been determined that mite positivity increases with age in blepharitis and control groups. In the group with blepharitis, it was found that mite positivity was significant in the presence of symptoms and Demodex positivity decreased as the education level of individuals increased.

The results of the study show that Demodex spp. infestations should be considered in chronic blepharitis and chalazion.

SOURCE: Akkucuk S, Kaya OM, Aslan L, et al. Prevalence of Demodex folliculorum and Demodex brevis in patients with blepharitis and chalazion. Int Ophthalmol. 2022; Oct 18. [Epub ahead of print].






Industry News

Euclid Vision Announces Winners of Inaugural Resident Scholarship Award

Euclid Vision announced the winners of its inaugural Euclid Resident Scholarship Awards, recognizing innovation in myopia management and orthokeratology. The following optometry residents were each awarded $1,000 for their myopia-related educational projects at the annual meeting of the American Academy of Optometry in San Diego: Zachary Reynard, OD, University of Alabama at Birmingham School of Optometry; Kevin Feng, OD, Pennsylvania College of Optometry, Salus University; and Cindy Shan, OD, Northeastern State University Oklahoma, College of Optometry. Learn more.

MaximEyes EHR Software Receives Another Industry Certification

First Insight, developer of MaximEyes certified optometry and ophthalmology EHR software, has received the Office of the National Coordinator for Health Information Technology 2015 Edition Cures Update Certification. Learn more.












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

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