Sleep Apnea and NPDR

HOT TOPIC

B+L Announces Purchase of Trukera

Bausch + Lomb has acquired ophthalmic medical diagnostic company Trukera Medical.

The acquisition will undoubtedly help Bausch + Lomb’s presence in the most significant dry eye and surgical clinics in the United States and worldwide. It will also contribute to the company’s quickly growing dry eye portfolio. Trukera Medical commercializes and sells the portable, point-of-care ScoutPro Osmolarity System. Years ago, a similar machine was available from the company called the Tear Lab Osmolarity System. (As a refresher, hyperosmolarity is a condition can’t be detected with a standard slit-lamp examination and is a leading indicator of dry eye that can affect a patient’s ocular comfort and surgical outcomes if not addressed preoperatively.)

Trukera was founded in 2009 as TearLab and introduced the concept of tear osmolarity testing with its TearLab Osmolarity system, which has been used to perform more than 24 million tests worldwide. In 2022, the company changed its name to Trukera Medical, as it expanded into corneal health.

My Two Cents

Roughly 20 to 30 patients have their tear osmolarity measured every day in my clinic. Each staff member is trained on the ScoutPro Osmolarity System, and I am a zealot for using it on each patient with dry eye at nearly every visit. Although we don’t make much money on the procedure, and it takes substantial staff time to run it, tear osmolarity is an indispensable data point in my treatment algorithm—along with InflammaDry (Quidel, now distributed through Dry Eye Rescue). Here’s hoping that B+L’s impressive culture of innovation will take the ScoutPro Osmolarity System and improve its function to make it faster, more accurate/reliable, and possibly include other data points. Hey B+L—how about including a matrix metalloproteinases-9 detector, other inflammatory markers, allergy markers, or adenovirus markers?

OUTSIDE THE LANE

Could Sleep Apnea Have an Effect on DR?

A new study has shown that patients with existing nonproliferative diabetic retinopathy (NPDR) and obstructive sleep apnea (OSA) have a significantly higher risk of progression, complications, interventions, and systemic events when compared with patients with NPDR and no OSA.

The study found that in patients with existing NPDR, OSA increased the risk of progression to proliferative diabetic retinopathy by 75% at 1 year compared with patients who had NPDR and no OSA. This significant statistical difference remained out to 5 years. Not shockingly, the likelihood of newly diagnosed diabetic macular edema and other ocular interventions increased significantly within 1 year and continued through 5 years out in patients with OSA.

At the recent American Society of Retina Specialists meeting, Ehsan Rahimy, MD, of Stanford University, commented, “Consistent with other studies, the risk of systemic events—stroke, myocardial infarction, and premature death—also were significantly higher in patients with NPDR and OSA.”

Other doctors acknowledged some difficulty in the study’s metrics. Tongalp Tezel, MD, of Columbia University, stated that the association between OSA and diabetic progression “is like a chicken/egg problem. Diabetics have a higher rate of obstructive sleep apnea because they have autonomic nerve dysfunction, which affects the respiratory system, but autonomic nerve dysfunction is also a cause of progression of diabetes. How do you isolate obstructive sleep apnea?”

My Two Cents

What a fascinating study! Although Dr. Tezel brings up a great point regarding the difficulty of isolating sleep apnea, the results of the study are, in my opinion, impressive. That 75% increase in the risk of progression of NPDR to PDR in those patients with OSA when compared with those without is almost hard to believe. Hopefully this study will spur further research into this topic!

CAN YOU RELATE

As part of my job at Williamson Eye Center, I get one of “those patients” referred to me nearly every day from either an outside OD, word of mouth, or one of our internal physicians. I’m talking about those patients who are never quite happy with their current refractive option or may have had a previous surgery that did not quite yield them the vision they desire, oftentimes post-refractive surgery patients—notably post-RK surgery or, as I call them, the gift that keeps giving.

It's rare that one of our own post LASIK patients end up unhappy in my chair; however, there is one particular patient who I have been working with for some time. He is a 39-year-old who elected to undergo LASIK, understanding that due to his large amount of astigmatism, his entire refractive error would not be fully corrected. He was not interested in an implantable collamer lens or clear lens exchange surgery. Despite being fully informed about the residual blur that would occur after surgery and being told that the purpose of the surgery was to make him less reliant on glasses and contact lenses, he was unhappy with his surgical outcome. After being fit in glasses and soft contact lenses by other providers, the patient achieved (objectively) good visual acuity; however, he remained unhappy, so he was referred to me for a consult on other options. We decided to look into specialty lenses, and due to his previous dislike of “the little hard lenses,” we opted for scleral lenses. Here’s the interesting thing: This patient’s horizontal visible iris diameter/horizontal white-to-white, measured using the Pentacam (Oculus), was 11.2 mm. That’s a pretty tiny cornea, and I knew that going into the battle. However, due to his deep-set eyes and small cornea, I finally gave up on scleral lenses. After four remakes of the amazing Onefit Med lens (Blanchard Lab/CooperVision Specialty Eye Care), I was down to 14.6 mm scleral on my last lens.

After examining all options, I decided to attempt an RGP fit. I sat the patient down and convinced him to try these lenses again because I felt it was his best option. Thankfully (and luckily), he trusted me, and we decided to give it another shot. After two remakes, we ended up with a 9.5-mm diameter bitoric minus carrier RGP lens. The patient achieved better than 20/20 vision and had tears in his eyes because he had never seen so well.

All this to say, don’t forget about your friendly RGP lenses from your specialty lens labs. Not only has technology advanced substantially in scleral lenses, progressive glasses, and scleral lenses, but so too has it come a long way in RGP lenses. The materials are superior, the edges more forgiving, and the coatings better than ever. Had I given up because the scleral lenses failed, this patient would have remained unhappy for who knows how long. RGPs are forgotten heroes of the contact lens world!