People with OSA are vulnerable to certain ocular ailments, and therapies should be considered to offer relief.

Obstructive sleep apnea (OSA) can impact many different organs in the human body. Though not given as much attention as the sleep disorder’s serious cardiovascular or neurological consequences, OSA’s negative impact on the eyes can be a source of misery for untreated and treated OSA patients alike.

Any clinician, whether family practitioner, pulmonologist, OB/GYN, or other professional, should be asking CPAP (continuous positive airway pressure) users if they suffer from dry eyes, says Art Epstein, OD, FAAO, FABCO, FBCLA, DPNAP. Epstein is director of Clinical Research & the Dry Eye and Ocular Surface Disease Center at Phoenix Eye Care, PLLC, a primary eye care practice with a focus on helping patients with dry eyes. About 10% of his patients are CPAP users, and many of them come in with dry eyes, Epstein says. He helps these patients by providing treatments that can improve symptoms and, in some cases, even prevent more serious optical problems.

Dry Eye Causes in OSA Patients

Floppy eyelid syndrome. Slack eyelids that easily turn inside-out are hallmarks of floppy eyelid syndrome, a syndrome that has been linked to OSA. Because the slack, sometimes everted, lids are not as protective as healthy eyelids, patients with floppy eyelid syndrome are at risk of nocturnal mechanical irritation caused by such events as the eye rubbing directly against a pillow. This can lead to more serious problems such as keratoconus, and has also been linked to meibomian gland dysfunction. “Floppy eyelid syndrome can persist even once patients are treated for OSA,” Epstein says.

Keratoconus. A thinning disorder of the cornea, keratoconus is typically inherited but may be worsened by eye rubbing and lack of eye protection when sleeping. “A lot of those patients who develop keratoconus have floppy eyelid syndrome, which impacts lid closure and protection, thereby worsening the development and progression of keratoconus,” Epstein says.

Meibomian glands dysfunction (MGD). MGD is the leading cause of dry eye, says Epstein. When functioning properly, the meibomian glands, which line the inside of the eyelids, squeeze out a complex oil that serves as an evaporative barrier. Mixing with tears, the gland secretions result in a stable tear film that provides adequate eye moisture and lubrication. When the secretion isn’t sufficient or of good enough quality, MGD and dry eye results. “An epiphany in the treatment of dry eye is that dry eye is a structural and a functional problem, more so than a simple absence of tears,” Epstein says.

CPAP therapy side effects. Air blowing directly into the eyes from a CPAP mask leak (or even from a ceiling fan) can result in dry eye. Interface leaks may be alleviated by a better fitting or a different mask, an option sleep clinicians are well suited to employ. Epstein explains what he has seen in patients when air blows over their eyes while they are asleep. “Even if the eye appears shut when sleeping, the eye may not fully close,” Epstein says. “Sometimes they’ll wake up with abrasions, in pain, or not seeing well. And in the morning, it may take a while to get their tears going again.”

Some patients may also have a poor Bell’s phenomenon, which can compound a dry eye problem or can cause a problem independently. Bell’s phenomenon is a reflex that in healthy patients causes upward and outward movement of the eye, when an attempt is made to close the eyes. But for patients that lack a good Bell’s phenomenon, the cornea may be exposed and dry out. “In sleep apnea patients, having a poor Bell’s phenomenon is all the worse, because not only is the patient suffering from exposure and lack of good lid function, but they also have high velocity air blown over their lids and right on to their sensitive corneas.”

Solutions to Sleep-Related Dry Eye


EyeEco’s Eyeseals 4.0 gently shelter eyes from leaking air and naturally increase relative humidity, hydrating the sensitive eyelid skin.

Hydrating nighttime eye shelters. Protecting the eye through a fitted covering at night can alleviate and prevent dry eye and mechanical rubbing. Epstein finds success recommending EyeEco’s shelters to his patients. The Eyeseals 4.0, Onyix, and Quartz shelters, which resemble goggles, were made with CPAP users in mind and not only protect the eye but also create a helpful humid environment. “I consider them an ounce of prevention,” Epstein says. The products create a moisture-tight seal that holds onto tears and sweat. “These EyeEco products create 100% humidity under them, so even if the eye is open, it doesn’t matter. Even if air is flowing over the eyes, it doesn’t matter.”

Prior to discovering the EyeEco products, Epstein would prescribe other methods to protect and hydrate patients’ eyes at night, with limited and varying degrees of success. “We’d use thick oil-based ointments, but the ointments would gum up their eyes. We’d also sometimes try taping their eyes shut or would use other eye masks, but the masks would move around,” he says.

Triglyceride-based omega-3. Epstein says some of his dry eye patients have been helped by the triglyceride-based omega-3 supplement, which is available over the counter in capsule and liquid forms. “Omega-3 provides the building blocks for eye glands to make oils,” he says. Epstein frequently recommends PRN (Physicians’ Recommended Neutraceuticals) branded dry eye products, but other brands are available. Make sure that they are a triglyceride-based product. Most aren’t, he cautions.

Eyelid and eyelash cleansers. A variety of over-the-counter and prescription eyelid and eyelash cleansers are available for dry eyes. Epstein finds Avenova (prescription-required) to be effective. “It contains hypochlorous acid, which is produced normally by the body’s white cells to fight infection, and it reduces overpopulation of staph,” he says. He also recommends EyeEco’s Tea Tree Eyelid & Facial Cleanser product line for patients.

Vectored thermal pulsation. For patients whose meibomian glands are obstructed, another option to consider is LipiFlow. TearScience’s LipiFlow vectored thermal pulsation employs an algorithm of precise heat applied to the inner eyelids and directed gentle massage to remove blockages from the meibomian glands.

Identifying and treating dry eye in OSA patients can result in CPAP users who have higher quality of life and who are satisfied with their care.

Sree Roy is editor of Sleep Review.