Photo Credit: Mongkolchon
In patients with diabetic retinopathy, obstructive sleep apnea increases the risk for proliferative diabetic retinopathy, intravitreal injection, and stroke.
Patients with nonproliferative diabetic retinopathy (NPDR) progression are more likely to have serious vision-threatening and systemic complications and to die if they also have obstructive sleep apnea (OSA), according to findings published in the American Journal of Ophthalmology.
“Patients with OSA carried an increased risk of developing [vision-threatening complications (VTCs)], progression to [proliferative diabetic retinopathy (PDR)] or [diabetic macular edema (DME)], and need for subsequent ocular intervention with intravitreal injection pharmacotherapy or laser photocoagulation over a 5-year period compared with patients without OSA,” study author Ehsan Rahimy, MD, and colleagues wrote.
“We observed a significantly elevated risk of experiencing systemic events in individuals with OSA, including stroke, [MI (myocardial infarction)], and death during the same time interval,” the researchers added.
Diabetic retinopathy and its sequelae, retinal neovascularization leading to PDR and DME, are leading causes of preventable blindness in working-age people. Studies have shown an association between DR and OSA, the latter of which affects an estimated 22% of men and 17% of women, with incidence rising along with obesity. In addition, OSA affects between 58% and 86% of people with diabetes.
Study Parameters & Baseline Characteristics
Dr. Rahimy and colleagues retrospectively reviewed the records of patients with NPDR in the TriNetX electronic health records network from January 2003 through October 2023. They divided participants into two groups: those with OSA and those without OSA. Patients with a history of proliferative disease, diabetic macular edema, or prior ocular intervention were excluded.
At baseline, the average age was 67.8 years for participants with OSA and 68.0 years for those without OSA; 50.5% of participants were men. In addition to diabetes, more than 95% of patients in both groups had concurrent hypertension, more than 85% had hyperlipidemia, and more than 80% had a diagnosis of overweight or obesity.
Increased Risk With OSA in Both PDR & NPDR
After performing propensity score matching to control for baseline demographics and comorbidities, the researchers analyzed data from 11,931 participants with OSA and 11,931 without OSA. They measured rates of progression to vision-threatening complications, need for ocular intervention, and systemic events at 1, 3, and 5 years.
They found:
- Increased risk for PDR in the OSA cohort at 1 (risk ratio [RR], 1.34; P<0.001), 3 (RR,1.31; P<0.001), and 5 years (RR, 1.28; P<0.001); elevated risk for DME in the OSA group at 1 (RR, 1.31; P<0.001), 3 (RR, 1.19; P<0.001), and 5 years (RR, 1.18; P<0.001).
- Increased risk for intravitreal injection in patients with NPDR and OSA at 1 (RR, 1.59; P<0.001), 3 (RR, 1.58; P<0.001), and 5 years (RR, 1.54; P<0.001), with similar trends for laser photocoagulation but not for vitrectomy.
- Increased risk for stroke in patients with NPDR and OSA at 1 year (RR, 1.80; P<0.001), 3 years (RR, 1.56; P<0.001), and 5 years (RR, 1.49; P<0.001); for MI at 1 year (RR, 1.51; P<0.001), 3 years (RR, 1.46; P<0.001), and 5 years (RR, 1.43; P<0.001); and for death at 1 year (RR, 1.31; P<0.001), 3 years (RR, 1.19; P<0.001), and 5 years (RR, 1.15; P<0.001).
Directions for Future Research
Study investigators acknowledged limitations of the study, including the possible misclassification of ICD-10 stage or DME status, the inability to gain deeper insights into OSA severity or management due to lack of polysomnography reports, and the inability to measure patient adherence to recommended OSA therapy.
“Further prospective studies are warranted to better characterize this complex relationship between DR and OSA,” Dr. Rahimy and colleagues wrote. “However, our findings emphasize the need for improved screening measures of patients with NPDR being monitored by eye care providers to potentially uncover underlying OSA and generate referrals for appropriate management.”
Create Post
Twitter/X Preview
Logout