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Clinical and Experimental Ophthalmology 2015; 43: 405–408 doi: 10.1111/ceo.12483
Original Article Endoscopic dacryocystorhinostomy and obstructive sleep apnoea: the effects and outcomes of continuous positive airway pressure therapy Mohammad J Ali FRCS,1 Alkis J Psaltis PhD FRACS,2 Jae Murphy MBBS2 and Peter John Wormald MD FRACS2 1
Dacryology Service, L.V. Prasad Eye Institute, Hyderabad, India; and 2Department of Surgery-Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, South Australia, Australia
ABSTRACT
H20). Eighty per cent (8/10) of patients complained of symptoms from the use of their CPAP following DCR. The most commonly described symptom was that of air regurgitation in 70% of patients followed by ophthalmic symptoms in 60% (6/10). 50% (5/10) of patients discontinued their CPAP as a consequence of their symptoms with 20% (2/10) discontinuing because of intolerable ophthalmic symptoms.
Background: This study aims to assess the effects and outcomes of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA) in patients who have undergone endoscopic dacryocystorhinostomy (DCR). Design: Retrospective series in a university setting. Participants: A total of 205 consecutive patients were included in this study. Methods: A 10-year retrospective review was performed of 205 consecutive patients who had undergone powered endoscopic DCR for nasolacrimal duct obstruction. Patient notes were reviewed for demographic, clinical and surgical information. In addition, all patients were contacted and asked to complete a standardized telephone survey relating to OSA, CPAP use and associated symptoms. Main Outcome Measure: Effects of CPAP following DCR. Results: Ten of the 205 patients undergoing DCR were identified to use CPAP for obstructive sleep apnoea. Eight patients were initiated on a nasal device, while two used a full-face mask. The mean CPAP pressures were 8 cm H20 (range: 6–10 cm
Conclusion: Symptoms from CPAP use postendoscopic DCR are a common occurrence and may contribute to poor compliance with CPAP therapy. Detailed preoperative counseling with regards to CPAP use and its effects should be mandatory in known or at risk OSA patients undergoing DCR. Key words: sleep apnea, CPAP, endoscopic DCR, air regurgitation.
INTRODUCTION Obstructive sleep apnoea or OSA is an underdiagnosed entity characterized by spells of breathing cessation for at least 10 s secondary to upper airway obstruction.1,2 Affected patients have an increased morbidity and mortality from depression, hypertension, diabetes, cardiovascular and cerebrovascular complications as well as road traffic accidents.3
■ Correspondence: Professor Peter John Wormald, The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, 5011, South Australia, Australia. Email: [email protected] Received 29 June 2014; accepted 12 November 2014. Conflict of interest: Peter Wormald receives royalties from Medtronic for design of instruments and is a consultant to Nielmed. No conflicts of interest for other authors. Funding sources: No stated funding sources. © 2014 Royal Australian and New Zealand College of Ophthalmologists
406
Ali et al.
Continuous positive airway pressure or CPAP therapy remains the cornerstone in the treatment of moderate to severe OSA with improvements noted in quality of sleep and quality of life as early as after a single night’s use.4–6 Dacryocystorhinostomy (DCR) is a commonly performed procedure for treatment of nasolacrimal duct obstructions.7,8 Several studies have documented ophthalmic complications from the use of CPAP alone or following a DCR, and these include severe air regurgitation, dry eyes, vascularized limbal keratitis, conjunctivitis and recurrent microbial keratitis.9–15 Much of the literature published on CPAP complications following a DCR is related to patients undergoing placement of Lester Jones (LJ) tubes.10–13 To the best of the authors’ knowledge, only two studies (total three patients) have discussed the effects of CPAP following a regular dacryocystorhinostomy (two external and one endoscopic).14,15 The current study analyses the prevalence of obstructive sleep apnoea and issues with CPAP use after a DCR among a large cohort of 205 patients.
Table 1.
METHODS
CPAP, continuous positive dacryocystorhinostomy.
A retrospective review was performed of 205 consecutive patients (after excluding nine paediatric patients) undergoing powered endoscopic DCR’s as described by Wormald et al.7 over a 10-year period from 2002 to 2012. Institutional review board approval was obtained. Patient records were reviewed for demographic data, clinical profiles, surgical notes, sleep specialist visits, OSA diagnosis, CPAP initiation and maintenance and follow-up. An attempt was made to contact all patients identified in this study period by telephone so that a standardized verbal questionnaire could be administered. This questionnaire (Table 1) asked whether or not they had a sleep study proven diagnosis of OSA and whether or not they were undergoing management with CPAP. In addition, it addressed issues concerning compliance, comfort and complications associated with CPAP use.
RESULTS
DCR and CPAP: parameters enquired
• OSA diagnosis: Yes/No • Patient using CPAP: Yes/No If Yes Sleep apnoea diagnosis: Before/after DCR surgery CPAP Initiation: Before/after DCR Surgery CPAP and DCR – Preceding/following time interval Duration of CPAP use Device being used: Nasal mask/Full-face mask Current CPAP pressure Symptoms, their duration, frequency and severity Air regurgitation/blow of air on to the eyes Epiphora Irritation Dry eyes Itchy eyes Redness Pain History of eye infections Nasal/throat dryness Patient coping measures for symptoms, if any Sleep comfort with symptoms, if any Any consultation for symptoms: Ophthalmologist/sleep specialist Any medications advised Any change of device suggested Any change of pressure suggested Any recurrent symptoms following medications/change of device airway
pressure;
DCR,
Demographic and clinical information Demographic data and clinical information for this subset of patients is summarized in Table 2. In brief, the mean age of these patients was 55.3 years (range: 50–73 years). Four patients were diagnosed with OSA and commenced CPAP before DCR and six after the DCR had already been performed. For the patients diagnosed with OSA prior to surgery, the mean time interval between OSA diagnosis and DCR was 3.7 years. The mean duration of CPAP use at the time of assessment was 18.8 months (range 1–48 months). Eight patients were initiated on a nasal device and two on full-face mask. The mean CPAP pressures were 8 cm H20 (range: 6–10 cm H20).
Symptoms associated with CPAP use
Prevalence Two hundred five DCR patients were identified during the 10-year study period. Of these, valid and active telephone numbers were available for only 123 (60%) of the initial cohort. Four patients were identified as having OSA requiring CPAP use on case note review with a further six captured during the telephone interview. This resulted in a cohort prevalence of 8.1% (10/123) of DCR patients requiring CPAP for coexistent OSA.
Seventy per cent (7/10) of patients described symptoms of air regurgitation through their lacrimal system, and 60% (6/10) had additional eye symptoms of dryness, irritation and redness. Three patients described persistent eye symptoms, whereas the other three only had them occasionally. None of the patients had documented ocular infections. Eighty per cent (8/10) of patients had symptoms of nasal and throat dryness with 50% of them (4/8) having them persistently.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Endoscopic DCR and obstructive sleep apnoea Table 2. S. No 1 2 3 4 5 6 7 8 9 10
407
Details of the DCR patients using CPAP Age/sex
SA diagnosis
CPAP
Device
Pressure
Air reflux
Eye symptoms
N–T symptoms
Changes made
Final outcome
56/F 69/M 69/F 51/M 50/F 73/F 62/F 62/F 63/F 60/F
Aft DCR Aft DCR Bef DCR Bef DCR Aft DCR Bef DCR Aft DCR Aft DCR Aft DCR Bef DCR
24 m 7m 24 m 24 m 12 m 15 m 3m 1m 48 m 40 m
Nasal Nasal Nasal Face Nasal Nasal Nasal Nasal Face Nasal
10 cmH20 8 cmH20 8 cmH20 8 cmH20 7 cmH20 7 cmH20 9 cmH20 10 cmH20 6 cmH20 7 cmH20
Y Y Y N Y Y Y Y N N
Y/A Y/O Y/O N Y/O N Y/A Y/A N N
Y/A Y/A Y/O Y/O Y/O N Y/A Y/A N Y/O
Press ↓ HHT/Lub Lub HHT HHT/Lub N Face Press ↓ N Eye pad/Lub
Good xCPAP/OR xCPAP/Oph Good xCPAP/OR Good xCPAP/Oph xCPAP/OR Good Good
Aft, after; Bef, before; cmH20, centimetres of water; CPAP, continuous positive airway pressure; DCR, dacryocystorhinostomy; Good, continuing CPAP and satisfied; Face, full-face mask; HHT, heater humidifier tubing; Lub, lubricants; m, months; Nasal, nasal mask; N–T, nose, throat symptoms; N, no; Press↓, pressure decreased; SA, sleep apnoea; xCPAP/Oph, stopped CPAP for ophthalmic reasons; xCPAP/OR, stopped CPAP for other reasons; Y, yes; Y/A, yes and always; Y/O, yes and occasional.
As a consequence of their symptoms, eight patients required intervention. Additional topical ocular lubrication was prescribed in four patients, three patients were advised to use heated humidifier tubings, two patients needed their delivery pressures reduced, and a further patient required a change of their CPAP mask from a nasal one to a full-face mask.
Compliance with CPAP As a consequence of their symptoms, 50% (5/10) admitted to stopping the use of their CPAP machine with the reasons cited as intolerable ophthalmic symptoms in two patients and claustrophobia, persistent OSA morbidity and no improvement in nose and throat dryness being the other reasons.
DISCUSSION This study broadly reflects the general and specific issues of patients using CPAP following DCR, with air regurgitation and ocular irritation the most common complaints. From our study, the overall CPAP-related outcomes appear to be much better in endoscopic DCR with these patients tolerating CPAP better than those in whom LJ tubes have been inserted. Face mask appears to be a better choice of device than a nasal mask in post-DCR patients. CPAP, which is currently considered the gold standard medical treatment for OSA, machine delivers air at a constant pressure (usually 6–12 cm H2O) predetermined by the results of polysomnography testing and CPAP trial. General complaints with CPAP machines include face discomfort, claustrophobia, facial dermatitis, air leaks, nasal and throat dryness, epistaxis and aerophagia.16,17
Although many ophthalmic associations of OSA are documented and include floppy eyelids, glaucoma, ischemic optic neuropathy and papilloedema,18,19 several ophthalmic complications occur with the use of CPAP. These include dry eyes, air regurgitation and microbial conjunctivitis and keratitis.9–15 Much of the literature documenting problems with CPAP have been reported in patients undergoing conjunctival DCR with LJ tube placement.10–13 Only two studies with a total of three patients (two external and one endoscopic) between them reported issues with CPAP after routine DCR.14,15 Cannon PS et al.14 reported discomforting air regurgitation in all their four patients (two with LJ, one external and one endoscopic DCR). One patient had his LJ tube removed with resolution of air regurgitation, whereas the remaining three continued to be symptomatic in spite of change of device, decreased pressure and application of barrier ointments. Mezanna et al.15 described a single patient who developed conjunctival irritation due to air reflux following an external DCR. They reported complete relief from symptoms with white petrolatum and mineral oil ophthalmic ointment, and subsequently the patient was able to tolerate CPAP use. Longmire et al.10 reported a single patient who stopped using CPAP following LJ tube insertion because of intolerance to air regurgitation. Fortunately, the patient was weaned off the CPAP after his OSA improved with weight loss after a bariatric surgery. Servat et al.11 reported a single patient with bilateral LJ tubes, who developed superficial punctuate keratopathy and papillary conjunctivitis in three weeks after CPAP initiation. The CPAP nasal mask was changed to a full-face device incorporating both the tubes within the pressure circuit, and this
© 2014 Royal Australian and New Zealand College of Ophthalmologists
408
Ali et al.
resulted in resolution of symptoms, and the patient continued to use CPAP successfully.11 The patients in the current series appear to have less severe symptoms than those reported with the use of LJ tubes. Several case reports exist documenting patients’ selfdeveloped innovations to combat air regurgitation. Goldberg12 reported a patient who blocked the external end of an LJ tube with wet cotton. Cartwright et al.13 described how a patient created an alginate mould and fitted it in a CPAP machine to counteract the pressure gradient across the LJ tube. The current study supports the view that all patients considering DCR surgery who are known OSA patients or those at high risk of developing OSA (obese, short necks, elderly) should be counseled about the use of CPAP and its general and eye-specific complications after DCR surgery. As the incidence of obesity and consequently OSA increases with greater use of CPAP, the potential risks of CPAP associated with a DCR need to be considered and discussed with these patients. In conclusion, ophthalmologists should be aware of the ophthalmic side effects of using CPAP after DCR surgery and should work closely with the sleep specialists for better patient outcomes. Monitoring these patients regularly, more so during the initial phase helps in prevention, recognition and treatment of ophthalmic complications.
REFERENCES 1. Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med 2005; 142: 187–97. 2. Malhotra A, White DP. Obstructive sleep apnea. Lancet 2002; 360: 237–45. 3. Ge X, Han F, Huang Y et al. Is obstructive sleep apnea associated with cardiovascular and all cause mortality? PLoS ONE 2013; 8: e69432. 4. Kapur VK. Obstructive sleep apnea: diagnosis, epidemiology and economics. Respir Care 2010; 55: 1155–67. 5. McDaid C, Griffin S, Weatherly H et al. Continuous positive airway pressure devices for treatment of obstructive sleep apnea-hypopnea syndrome: a systematic review and economic analysis. Health Technol Assess 2009; 13: 1–119.
6. Moyer CA, Sonnad SS, Garetz SL, Helman JI, Chervin RD. Quality of life in obstructive sleep apnea: a systematic review of the literature. Sleep Med 2001; 2: 477–91. 7. Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope 2002; 112: 69–71. 8. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 2003; 135: 76–8. 9. Harrison W, Pence N, Kovacich S. Anterior segment complications secondary to continuous positive airway pressure machine treatment in patients with obstructive sleep apnea. Optometry 2007; 78: 352–5. 10. Longmire MR, Carter KD, Allen RC. Intolerance of Jones tube placement in a patient using continuous positive airway pressure. Ophthal Plast Reconstr Surg 2010; 26: 68–9. 11. Servat JJ, Black EH, Gladstone GJ. A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma? Ophthal Plast Reconstr Surg 2012; 28: e151–2. 12. Goldberg DS. Management of air regurgitation through a Jones tube in a patient using continuous positive airway pressure. Ophthal Plast Reconstr Surg 2011; 27: e76–7. 13. Cartwright MJ, Frueh BR. Keratoconjunctivitis sicca in a patient with a Jones tube to treat sleep apnea. Am J Ophthalmol 1992; 114: 234–5. 14. Cannon PS, Madge SN, Selva D. Air regurgitation in patients on continuous positive airway pressure (CPAP) therapy following dacryocystorhinostomy with or without Lester-Jones tube insertion. Br J Ophthalmol 2010; 94: 891–3. 15. Mezzana P, Marabottini N, Scarinci F, Pasquini P. An unusual case of conjunctival irritation and epiphora following external dacryocystorhinostomy. J Laryngol Otol 2011; 125: 1073–4. 16. Rolfe I, Olson LG, Sanders NA. Long term acceptance of continuous positive airway pressure in obstructive sleep apnea. Am Rev Respir Dis 1991; 144: 1130–3. 17. Engleman HM, Martin SE, Douglas NJ. Compliance with CPAP therapy in patients with sleep apnea/ hypopnea syndrome. Thorax 1994; 49: 263–6. 18. Waller EA, Bendell RE, Kaplan J. Sleep disorders and the eye. Mayo Clin Proc 2008; 83: 1251–61. 19. McNab AA. The eye and sleep apnea. Sleep Med Rev 2007; 11: 269–76.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Clinical and Experimental Ophthalmology 2015; 43: 405–408 doi: 10.1111/ceo.12483
Original Article Endoscopic dacryocystorhinostomy and obstructive sleep apnoea: the effects and outcomes of continuous positive airway pressure therapy Mohammad J Ali FRCS,1 Alkis J Psaltis PhD FRACS,2 Jae Murphy MBBS2 and Peter John Wormald MD FRACS2 1
Dacryology Service, L.V. Prasad Eye Institute, Hyderabad, India; and 2Department of Surgery-Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, South Australia, Australia
ABSTRACT
H20). Eighty per cent (8/10) of patients complained of symptoms from the use of their CPAP following DCR. The most commonly described symptom was that of air regurgitation in 70% of patients followed by ophthalmic symptoms in 60% (6/10). 50% (5/10) of patients discontinued their CPAP as a consequence of their symptoms with 20% (2/10) discontinuing because of intolerable ophthalmic symptoms.
Background: This study aims to assess the effects and outcomes of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA) in patients who have undergone endoscopic dacryocystorhinostomy (DCR). Design: Retrospective series in a university setting. Participants: A total of 205 consecutive patients were included in this study. Methods: A 10-year retrospective review was performed of 205 consecutive patients who had undergone powered endoscopic DCR for nasolacrimal duct obstruction. Patient notes were reviewed for demographic, clinical and surgical information. In addition, all patients were contacted and asked to complete a standardized telephone survey relating to OSA, CPAP use and associated symptoms. Main Outcome Measure: Effects of CPAP following DCR. Results: Ten of the 205 patients undergoing DCR were identified to use CPAP for obstructive sleep apnoea. Eight patients were initiated on a nasal device, while two used a full-face mask. The mean CPAP pressures were 8 cm H20 (range: 6–10 cm
Conclusion: Symptoms from CPAP use postendoscopic DCR are a common occurrence and may contribute to poor compliance with CPAP therapy. Detailed preoperative counseling with regards to CPAP use and its effects should be mandatory in known or at risk OSA patients undergoing DCR. Key words: sleep apnea, CPAP, endoscopic DCR, air regurgitation.
INTRODUCTION Obstructive sleep apnoea or OSA is an underdiagnosed entity characterized by spells of breathing cessation for at least 10 s secondary to upper airway obstruction.1,2 Affected patients have an increased morbidity and mortality from depression, hypertension, diabetes, cardiovascular and cerebrovascular complications as well as road traffic accidents.3
■ Correspondence: Professor Peter John Wormald, The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, 5011, South Australia, Australia. Email: [email protected] Received 29 June 2014; accepted 12 November 2014. Conflict of interest: Peter Wormald receives royalties from Medtronic for design of instruments and is a consultant to Nielmed. No conflicts of interest for other authors. Funding sources: No stated funding sources. © 2014 Royal Australian and New Zealand College of Ophthalmologists
406
Ali et al.
Continuous positive airway pressure or CPAP therapy remains the cornerstone in the treatment of moderate to severe OSA with improvements noted in quality of sleep and quality of life as early as after a single night’s use.4–6 Dacryocystorhinostomy (DCR) is a commonly performed procedure for treatment of nasolacrimal duct obstructions.7,8 Several studies have documented ophthalmic complications from the use of CPAP alone or following a DCR, and these include severe air regurgitation, dry eyes, vascularized limbal keratitis, conjunctivitis and recurrent microbial keratitis.9–15 Much of the literature published on CPAP complications following a DCR is related to patients undergoing placement of Lester Jones (LJ) tubes.10–13 To the best of the authors’ knowledge, only two studies (total three patients) have discussed the effects of CPAP following a regular dacryocystorhinostomy (two external and one endoscopic).14,15 The current study analyses the prevalence of obstructive sleep apnoea and issues with CPAP use after a DCR among a large cohort of 205 patients.
Table 1.
METHODS
CPAP, continuous positive dacryocystorhinostomy.
A retrospective review was performed of 205 consecutive patients (after excluding nine paediatric patients) undergoing powered endoscopic DCR’s as described by Wormald et al.7 over a 10-year period from 2002 to 2012. Institutional review board approval was obtained. Patient records were reviewed for demographic data, clinical profiles, surgical notes, sleep specialist visits, OSA diagnosis, CPAP initiation and maintenance and follow-up. An attempt was made to contact all patients identified in this study period by telephone so that a standardized verbal questionnaire could be administered. This questionnaire (Table 1) asked whether or not they had a sleep study proven diagnosis of OSA and whether or not they were undergoing management with CPAP. In addition, it addressed issues concerning compliance, comfort and complications associated with CPAP use.
RESULTS
DCR and CPAP: parameters enquired
• OSA diagnosis: Yes/No • Patient using CPAP: Yes/No If Yes Sleep apnoea diagnosis: Before/after DCR surgery CPAP Initiation: Before/after DCR Surgery CPAP and DCR – Preceding/following time interval Duration of CPAP use Device being used: Nasal mask/Full-face mask Current CPAP pressure Symptoms, their duration, frequency and severity Air regurgitation/blow of air on to the eyes Epiphora Irritation Dry eyes Itchy eyes Redness Pain History of eye infections Nasal/throat dryness Patient coping measures for symptoms, if any Sleep comfort with symptoms, if any Any consultation for symptoms: Ophthalmologist/sleep specialist Any medications advised Any change of device suggested Any change of pressure suggested Any recurrent symptoms following medications/change of device airway
pressure;
DCR,
Demographic and clinical information Demographic data and clinical information for this subset of patients is summarized in Table 2. In brief, the mean age of these patients was 55.3 years (range: 50–73 years). Four patients were diagnosed with OSA and commenced CPAP before DCR and six after the DCR had already been performed. For the patients diagnosed with OSA prior to surgery, the mean time interval between OSA diagnosis and DCR was 3.7 years. The mean duration of CPAP use at the time of assessment was 18.8 months (range 1–48 months). Eight patients were initiated on a nasal device and two on full-face mask. The mean CPAP pressures were 8 cm H20 (range: 6–10 cm H20).
Symptoms associated with CPAP use
Prevalence Two hundred five DCR patients were identified during the 10-year study period. Of these, valid and active telephone numbers were available for only 123 (60%) of the initial cohort. Four patients were identified as having OSA requiring CPAP use on case note review with a further six captured during the telephone interview. This resulted in a cohort prevalence of 8.1% (10/123) of DCR patients requiring CPAP for coexistent OSA.
Seventy per cent (7/10) of patients described symptoms of air regurgitation through their lacrimal system, and 60% (6/10) had additional eye symptoms of dryness, irritation and redness. Three patients described persistent eye symptoms, whereas the other three only had them occasionally. None of the patients had documented ocular infections. Eighty per cent (8/10) of patients had symptoms of nasal and throat dryness with 50% of them (4/8) having them persistently.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
Endoscopic DCR and obstructive sleep apnoea Table 2. S. No 1 2 3 4 5 6 7 8 9 10
407
Details of the DCR patients using CPAP Age/sex
SA diagnosis
CPAP
Device
Pressure
Air reflux
Eye symptoms
N–T symptoms
Changes made
Final outcome
56/F 69/M 69/F 51/M 50/F 73/F 62/F 62/F 63/F 60/F
Aft DCR Aft DCR Bef DCR Bef DCR Aft DCR Bef DCR Aft DCR Aft DCR Aft DCR Bef DCR
24 m 7m 24 m 24 m 12 m 15 m 3m 1m 48 m 40 m
Nasal Nasal Nasal Face Nasal Nasal Nasal Nasal Face Nasal
10 cmH20 8 cmH20 8 cmH20 8 cmH20 7 cmH20 7 cmH20 9 cmH20 10 cmH20 6 cmH20 7 cmH20
Y Y Y N Y Y Y Y N N
Y/A Y/O Y/O N Y/O N Y/A Y/A N N
Y/A Y/A Y/O Y/O Y/O N Y/A Y/A N Y/O
Press ↓ HHT/Lub Lub HHT HHT/Lub N Face Press ↓ N Eye pad/Lub
Good xCPAP/OR xCPAP/Oph Good xCPAP/OR Good xCPAP/Oph xCPAP/OR Good Good
Aft, after; Bef, before; cmH20, centimetres of water; CPAP, continuous positive airway pressure; DCR, dacryocystorhinostomy; Good, continuing CPAP and satisfied; Face, full-face mask; HHT, heater humidifier tubing; Lub, lubricants; m, months; Nasal, nasal mask; N–T, nose, throat symptoms; N, no; Press↓, pressure decreased; SA, sleep apnoea; xCPAP/Oph, stopped CPAP for ophthalmic reasons; xCPAP/OR, stopped CPAP for other reasons; Y, yes; Y/A, yes and always; Y/O, yes and occasional.
As a consequence of their symptoms, eight patients required intervention. Additional topical ocular lubrication was prescribed in four patients, three patients were advised to use heated humidifier tubings, two patients needed their delivery pressures reduced, and a further patient required a change of their CPAP mask from a nasal one to a full-face mask.
Compliance with CPAP As a consequence of their symptoms, 50% (5/10) admitted to stopping the use of their CPAP machine with the reasons cited as intolerable ophthalmic symptoms in two patients and claustrophobia, persistent OSA morbidity and no improvement in nose and throat dryness being the other reasons.
DISCUSSION This study broadly reflects the general and specific issues of patients using CPAP following DCR, with air regurgitation and ocular irritation the most common complaints. From our study, the overall CPAP-related outcomes appear to be much better in endoscopic DCR with these patients tolerating CPAP better than those in whom LJ tubes have been inserted. Face mask appears to be a better choice of device than a nasal mask in post-DCR patients. CPAP, which is currently considered the gold standard medical treatment for OSA, machine delivers air at a constant pressure (usually 6–12 cm H2O) predetermined by the results of polysomnography testing and CPAP trial. General complaints with CPAP machines include face discomfort, claustrophobia, facial dermatitis, air leaks, nasal and throat dryness, epistaxis and aerophagia.16,17
Although many ophthalmic associations of OSA are documented and include floppy eyelids, glaucoma, ischemic optic neuropathy and papilloedema,18,19 several ophthalmic complications occur with the use of CPAP. These include dry eyes, air regurgitation and microbial conjunctivitis and keratitis.9–15 Much of the literature documenting problems with CPAP have been reported in patients undergoing conjunctival DCR with LJ tube placement.10–13 Only two studies with a total of three patients (two external and one endoscopic) between them reported issues with CPAP after routine DCR.14,15 Cannon PS et al.14 reported discomforting air regurgitation in all their four patients (two with LJ, one external and one endoscopic DCR). One patient had his LJ tube removed with resolution of air regurgitation, whereas the remaining three continued to be symptomatic in spite of change of device, decreased pressure and application of barrier ointments. Mezanna et al.15 described a single patient who developed conjunctival irritation due to air reflux following an external DCR. They reported complete relief from symptoms with white petrolatum and mineral oil ophthalmic ointment, and subsequently the patient was able to tolerate CPAP use. Longmire et al.10 reported a single patient who stopped using CPAP following LJ tube insertion because of intolerance to air regurgitation. Fortunately, the patient was weaned off the CPAP after his OSA improved with weight loss after a bariatric surgery. Servat et al.11 reported a single patient with bilateral LJ tubes, who developed superficial punctuate keratopathy and papillary conjunctivitis in three weeks after CPAP initiation. The CPAP nasal mask was changed to a full-face device incorporating both the tubes within the pressure circuit, and this
© 2014 Royal Australian and New Zealand College of Ophthalmologists
408
Ali et al.
resulted in resolution of symptoms, and the patient continued to use CPAP successfully.11 The patients in the current series appear to have less severe symptoms than those reported with the use of LJ tubes. Several case reports exist documenting patients’ selfdeveloped innovations to combat air regurgitation. Goldberg12 reported a patient who blocked the external end of an LJ tube with wet cotton. Cartwright et al.13 described how a patient created an alginate mould and fitted it in a CPAP machine to counteract the pressure gradient across the LJ tube. The current study supports the view that all patients considering DCR surgery who are known OSA patients or those at high risk of developing OSA (obese, short necks, elderly) should be counseled about the use of CPAP and its general and eye-specific complications after DCR surgery. As the incidence of obesity and consequently OSA increases with greater use of CPAP, the potential risks of CPAP associated with a DCR need to be considered and discussed with these patients. In conclusion, ophthalmologists should be aware of the ophthalmic side effects of using CPAP after DCR surgery and should work closely with the sleep specialists for better patient outcomes. Monitoring these patients regularly, more so during the initial phase helps in prevention, recognition and treatment of ophthalmic complications.
REFERENCES 1. Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med 2005; 142: 187–97. 2. Malhotra A, White DP. Obstructive sleep apnea. Lancet 2002; 360: 237–45. 3. Ge X, Han F, Huang Y et al. Is obstructive sleep apnea associated with cardiovascular and all cause mortality? PLoS ONE 2013; 8: e69432. 4. Kapur VK. Obstructive sleep apnea: diagnosis, epidemiology and economics. Respir Care 2010; 55: 1155–67. 5. McDaid C, Griffin S, Weatherly H et al. Continuous positive airway pressure devices for treatment of obstructive sleep apnea-hypopnea syndrome: a systematic review and economic analysis. Health Technol Assess 2009; 13: 1–119.
6. Moyer CA, Sonnad SS, Garetz SL, Helman JI, Chervin RD. Quality of life in obstructive sleep apnea: a systematic review of the literature. Sleep Med 2001; 2: 477–91. 7. Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope 2002; 112: 69–71. 8. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 2003; 135: 76–8. 9. Harrison W, Pence N, Kovacich S. Anterior segment complications secondary to continuous positive airway pressure machine treatment in patients with obstructive sleep apnea. Optometry 2007; 78: 352–5. 10. Longmire MR, Carter KD, Allen RC. Intolerance of Jones tube placement in a patient using continuous positive airway pressure. Ophthal Plast Reconstr Surg 2010; 26: 68–9. 11. Servat JJ, Black EH, Gladstone GJ. A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma? Ophthal Plast Reconstr Surg 2012; 28: e151–2. 12. Goldberg DS. Management of air regurgitation through a Jones tube in a patient using continuous positive airway pressure. Ophthal Plast Reconstr Surg 2011; 27: e76–7. 13. Cartwright MJ, Frueh BR. Keratoconjunctivitis sicca in a patient with a Jones tube to treat sleep apnea. Am J Ophthalmol 1992; 114: 234–5. 14. Cannon PS, Madge SN, Selva D. Air regurgitation in patients on continuous positive airway pressure (CPAP) therapy following dacryocystorhinostomy with or without Lester-Jones tube insertion. Br J Ophthalmol 2010; 94: 891–3. 15. Mezzana P, Marabottini N, Scarinci F, Pasquini P. An unusual case of conjunctival irritation and epiphora following external dacryocystorhinostomy. J Laryngol Otol 2011; 125: 1073–4. 16. Rolfe I, Olson LG, Sanders NA. Long term acceptance of continuous positive airway pressure in obstructive sleep apnea. Am Rev Respir Dis 1991; 144: 1130–3. 17. Engleman HM, Martin SE, Douglas NJ. Compliance with CPAP therapy in patients with sleep apnea/ hypopnea syndrome. Thorax 1994; 49: 263–6. 18. Waller EA, Bendell RE, Kaplan J. Sleep disorders and the eye. Mayo Clin Proc 2008; 83: 1251–61. 19. McNab AA. The eye and sleep apnea. Sleep Med Rev 2007; 11: 269–76.
© 2014 Royal Australian and New Zealand College of Ophthalmologists
