Associations between obstructive sleep apnoea, primary open angle glaucoma and age-related macular degeneration: record linkage study
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  • Published on:
    Obstructive sleep apnoea, primary open angle glaucoma and age-related macular degeneration
    • Tiarnan D Keenan, Clinical Fellow in Medical Retinal Disease 1. University of Manchester, Manchester, UK. 2. National Eye Institute, National Institutes of Health, Bethesda, MD, USA.
    • Other Contributors:
      • Raph Goldacre, Epidemiologist

    We thank the authors[1] but wish to clarify several points. Stating that ‘glaucoma diagnosis is more common in OSA populations’ is controversial. Glaucoma diagnosis was not more common in our study (RR 1.01, CI 0.85-1.19), which censored prospectively from time of OSA coding throughout England from 1999-2011[2]. This is the largest and longest individual study conducted in this area. Several previous studies also observed no association.

    The authors recommend accounting for ‘risk-associated conditions’. Accounting for potential confounders is important in evaluation of positive associations but less relevant in their absence. We agree that studies in different populations would be useful, particularly in Asia where OAG may differ.

    In recommending a prospective RCT assessing ‘IOP/visual field progression before and after CPAP’, the authors are asking a different question. We have previously advocated this: ‘even in the absence of a positive association, it might still be relevant to identify those patients with genuine co-existence of OSA and POAG, particularly if evidence were to emerge … that OSA treatment could reduce glaucomatous progression’[2].

    Our study never aimed to measure OSA point prevalence, so it is inappropriate to compare a speculative ‘base rate of 2.5%’ with prevalence estimates from a different continent/age-group. Moreover, our OSA cohort represented more severe disease; this should have exaggerated rather than ‘blurred’ any potentia...

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    Conflict of Interest:
    None declared.
  • Published on:
    Ophthalmologists wake obstructive sleeping dogma
    • Robert E Weir, Ophthalmology Doctor, Sleep Physician/Sleep Medicine Researcher Royal Eye Unit, Kingston Hospital
    • Other Contributors:
      • Kasia W Hozer, F2 Ophthalmology Doctor

    We read with great interest the article by Keenan et al. “Associations between obstructive sleep apnoea, primary open angle glaucoma and age-related macular degeneration: record linkage study” (Br J Ophthalmol. 2017 Feb;101(2):155-159), which concluded that Obstructive Sleep Apnoea (OSA) is not associated with Primary Open Angle Glaucoma (POAG). Potential POAG aetiology inflammatory markers are higher in OSA patients, and glaucoma diagnosis is more common in OSA populations.

    While retrospective studies have great value, it is important to account for risk-associated conditions, including family history of OSA, racial disparities [1], smoking, hypertension, floppy eyelids, Type II diabetes [2], COPD and obesity.

    To determine a causal relationship between OSA and POAG, it is necessary to assess intraocular pressures/visual field progression before and after continuous positive airway pressure (CPAP) treatment, using prospective randomised control trial designs. Further, the OSA base rate in Keenan et al. was 2.5%, while the estimated OSA prevalence rate may exceed 20% for those over 55 years of age [3]. Missing 90+% of apnoea sufferers may have blurred the true apnoea-POAG relationship. The risk rate for apnoea in the first year after initial POAG episode was 1.5, but declined to less than 1.0 in subsequent years, which suggests the possibility of increasing neglect of apnoea risk over the course of POAG. These findings highlight the lack of OSA screening and...

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    Conflict of Interest:
    None declared.