Ompriya Jayasankar, B.Sc. Ophthalmic Dispensing and Vision Science

M. Optometry Student, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.


Sleep Apnea (SA) is the most common sleep disorder characterised by repetitive episodes of cessation of breathing during sleep and results in transient nocturnal hypoxia and hypercapnia. Apnea clinically describes a complete pause of breathing for more than 10 seconds in adults. (1,2)

SA types are

  1. Central Sleep Apnea
    • It is a rare presentation
  2. Obstructive Sleep Apnea (OSA)
    • Most common form of sleep problem, over 85% of all cases


Figure 1: Symptoms of Sleep Apnea
Image courtesy:

SA places a higher burden on the health care system due to the higher prevalence of OSA and its associated health-related consequences. Specifically, episodic oxygen desaturation and agitation from sleep in OSA patients may contribute several mechanisms to the ocular complication which includes autonomic dysfunction with oxidative stress, dysregulation of circadian genes, endothelial dysfunction, and disruption of the blood-retinal barrier. Because of these adverse side effects, OSA can cause many eye diseases. Some of the ocular consequences are reversible, if not treated appropriately they may permanently threaten the patient’s vision. [2] [3]

Ocular complications associated with SA are presented in Table 1.

Table 1: Ocular complications of SA

Ocular manifestation of SA
Eyelid Floppy Eyelid Syndrome
Anterior segment Dry eye syndrome
Posterior segment Retinal vein occlusion
Central Serous Chorioretinopathy
Diabetic Retinopathy and Diabetic Macular Oedema
Optic nerve Glaucoma
Ischemic Optic Neuropathy
Orbit Thyroid Eye Disease

Floppy eyelid syndrome (FES):

FES is a palpebral laxity disorder. A study shows that, 96% of the patients had a symptom of FES associated with the OSA. (4) Wang et al. study confirmed that FES has a strong association with OSA compared to non-OSA. (5)

Dry eye syndrome (DES):

Decreased Schirmer’s value, represents aqueous deficient DES. Reduced tear break-up time and non-invasive tear breakup time, which suggests excessive tear evaporation, were detected in OSA. (6,7)

Keratoconus (KC):

Pellegrini et al found a significant association between OSA and KC [pooled Odds Ratio (OR]: 1.841, p = 0.009). (8)


Morsy, N.E et al. performed a cross-sectional case-control study that showed that there is a higher risk of developing cataracts associated with OSA. (9)

Retinal vein occlusion (RVO):

Agard et al reported that there is a significantly higher prevalence of OSA in RVO patients compared to the controls (adjusted OR: 5.65 (1.60–19.92), p = 0.007), but there was no significant relationship between the degree of OSA and RVO were noted. (10)

Central Serous Chorioretinopathy(CSCR):

Pan, C.K. et al study shows that the incidence of CSCR was higher in patients with OSA (HR: 1.081, p < 0.033). It is evident that an increased risk of CSCR in both genders among OSA. (11)


Some studies showed that they are more likely to have glaucoma among the patients with OSA. It shows that increased risk of developing open-angle glaucoma in association with OSA. (12, 13)

Ischemic Optic Neuropathy:

A meta-analysis of 4 prospective cohort studies and 1 case–control study reports that higher incidence of Non-Arteritic Ischemic Optic Neuropathy in OSA individuals when compared to the control group (pooled OR: 6.18 (2.00–19.11), p = 0.002). (14)


Thus, sleep is the essential process that helps the brain and body to get rest and it is apparent to the medical community. As health care professionals, it’s our duty and responsibility to address the signs and symptoms of this disorder. A recent study shows that ocular examination helps to rule out individuals who suffer from undiagnosed SA. So, eye care practitioners need to rule out patients with SA and refer them to a sleep specialist.



  1. Abdal, H., Pizzimenti, J. J., & Purvis, C. C. (2006). The eye in sleep apnea syndrome. Sleep medicine, 7(2), 107-115.
  2. Liu, P. K., Chiu, T. Y., Wang, N. K., Levi, S. R., & Tsai, M. J. (2021). Ocular complications of obstructive sleep apnea. Journal of Clinical Medicine, 10(15), 3422.
  3. Santos, M., & Hofmann, R. J. (2017). Ocular manifestations of obstructive sleep apnea. Journal of Clinical Sleep Medicine, 13(11), 1345-1348.
  4. McNab, A. A. (2007). The eye and sleep apnea. Sleep medicine reviews, 11(4), 269-276.
  5. Wang, P., Yu, D. J., Feng, G., Long, Z. H., Liu, C. J., Li, H., & Zhao, T. L. (2016). Is floppy eyelid syndrome more prevalent in obstructive sleep apnea syndrome patients? Journal of ophthalmology, 2016.
  6. Acar, M., Firat, H., Acar, U., & Ardic, S. (2013). Ocular surface assessment in patients with obstructive sleep apnea–hypopnea syndrome. Sleep and Breathing, 17, 583-588.
  7. Karaca, E. E., Akçam, H. T., Uzun, F., Özdek, Ş., & Çiftçi, T. U. (2016). Evaluation of ocular surface health in patients with obstructive sleep apnea syndrome. Turkish journal of ophthalmology46(3), 104.
  8. Pellegrini, M., Bernabei, F., Friehmann, A., & Giannaccare, G. (2020). Obstructive sleep apnea and keratoconus: a systematic review and meta-analysis. Optometry and Vision Science97(1), 9-14.
  9. Morsy, N. E., Amani, B. E., Magda, A. A., Nabil, A. J., Pandi-Perumal, S. R., BaHammam, A. S., … & Zaki, N. F. (2019). Prevalence and predictors of ocular complications in obstructive sleep apnea patients: a cross-sectional case-control study. The Open Respiratory Medicine Journal13, 19.
  10. Agard, E., El Chehab, H., Vie, A. L., Voirin, N., Coste, O., & Dot, C. (2018). Retinal vein occlusion and obstructive sleep apnea: a series of 114 patients. Acta Ophthalmologica96(8), e919-e925.
  11. Pan, C. K., Vail, D., Bhattacharya, J., Cao, M., & Mruthyunjaya, P. (2020). The effect of obstructive sleep apnea on absolute risk of central serous chorioretinopathy. American Journal of Ophthalmology218, 148-155.
  12. Lin, C. C., Hu, C. C., Ho, J. D., Chiu, H. W., & Lin, H. C. (2013). Obstructive sleep apnea and increased risk of glaucoma: a population-based matched-cohort study. Ophthalmology120(8), 1559-1564.
  13. Bendel, R. E., Kaplan, J., Heckman, M., Fredrickson, P. A., & Lin, S. C. (2008). Prevalence of glaucoma in patients with obstructive sleep apnoea—a cross-sectional case-series. Eye22(9), 1105-1109.
  14. Huon, L. K., Liu, S. Y. C., Camacho, M., & Guilleminault, C. (2016). The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis. Sleep and Breathing20, 1145-1154.