1. Tear-film Stability in Patients with Obstructive Sleep Apnea Syndrome Masaki Sato, MD Tetsuro Oshika, MD Department of Ophthalmology University of Tsukuba Japan The authors have no commercial or proprietary interest in any of the companies, products, or methods described in this presentation.

2.  Epidemiology ： About 20 million patients in the world  Classification ： Obstructive ・ Central  Symptoms ： Snore ・ Daytime somnolence （ The risk of the traffic accident : seven times ）  Risk factors ： Obesity ・ Respiratory diseases ・ Alcohol  Systemic complications ： Hypertension ・ Diabetes etc…  Diagnosis : Polysonography Apnea/Hypopnea Index (AHI) ≧ 5 times / hr  Therapy : nasal CPAP (nasal Continuous Positive Airway Pressure) Sleep Apnea Syndrome : SAS Introduction

3. Ocular manifestations  Glaucoma ： 2 ~ 27 % The retinal nerve fiber layer thickness correlates nagatively the SAS severity (Eye 2005, J Glaucoma 2007) Keratoconus Filamentary keratitis Reccurent corneal erosion Tear abnormality  Floppy eye lid : 52%  Corneal lesion The SLE-BUT correlates nagatively the SAS severity ? (Ophthalmology 1999) n= ？ Objective quantitative analysis !!

4. To evaluate the tear-film stability in patients with obstructive sleep apnea syndrome (OSAS) using the tear-film stability analysis system (TSAS). Purpose

5. Subjects & Methods Design ： cross-sectional study. Participants : Consecutive 116 left eyes of 116 cases on nCPAP therapy. Exclusion criteria : Contact lens wearing, post- intraocular surgery, other ocular disease, diabetes, and collagen disease. Subjects : 86 eyes of 86 cases （ M:F = 74:12 ） Age ： 55 ± 12 years ( range: 37-71 )

6. RT-7000 ® （ Tomey ） Corneal topographic maps each second for 10 seconds BUI (Breakup Index ; 0 〜 100) RBUT (Ring Breakup Time ; 0 〜 10) TSAS (Tear Stability Analysis System) Main Outcome Measures AHI （ at diagnosis / present ） BMI （ Body Mass Index ） Period of nCPAP therapy BUI RBUT

7. BUIRBUT rPrP Age AHI （ at diagnosis ） AHI （ at present ） BMI Period of nCPAP therapy 0.123 -0.273 0.004 -0.254 0.073 0.261 0.011 0.973 0.026 0.517 0.102 -0.265 -0.021 -0.067 0.052 0.349 0.014 0.854 0.570 0.647 (Pearson’s correlation coefficient) Results

8. r = -0.273 p = 0.0108 r = 0.004 p = 0.973 AHI (at diagnosis) BUI AHI (at present) Correlation between AHI and BUI (Pearson’s correlation coeffient)

9. r = -0.265 p = 0.0135 r = -0.021 p = 0.854 RBUT (Pearson’s correlation coeffient) Correlation between AHI and RBUT AHI (at diagnosis)AHI (at present)

10. １） Exacerbation of OSAS A long period before nCPAP therapy is started. ２） Influence of nCPAP (Optometry 2007) Ocular complications by nCPAP in 3 OSAS cases.  HCL wear for keratoconus → Keratoconjunctivitis  Injury for fellow eye → Keratoconjunctivitis  HCL wear for Pellucid cornea → Keratoconjunctivitis Inappropriate fitting of CPAP mask → leaking air Discussion The origin of the deteriorated tear-film stability…

11. Tear-film instability Keratoconjunctivitis Concept in Dry Eye MGD Conjunctiv ochalasis クリアランス 低 下 Moisture ↓ Stress CLwear Eye drops Medicine DM Trichiasis Injury Limbal function ↓ Surgery Lagophthalmos Sensation ↓ Nictation ↓ Inflammation Tear secretion ↓ Lid abnormality SAS

12.  The tear-film stability in OSAS patients correlates negatively with the AHI at diagnosis.  From the point of view of preventive medicine, it is very important for the OSAS patients to have the ophthalmic examinations. This research was partially supported by the Grant-in-Aid for Young Scientists (B) No.20791244 from MEXT Japan. Conclusions