1School of Drugs, King Faisal College, Al-Ahasa, Saudi Arabia; 2School of Drugs, King Saud College, Riyadh, Saudi Arabia; 3Division of Ophthalmology, School of Drugs, King Faisal College, Al-Ahasa, Saudi Arabia; 4Division of Vitreoretinal Surgical procedure, Dhahran Eye Specialist Hospital, Dhahran, Jap Province, Saudi Arabia
Correspondence: Ali A Al Saeed
School of Drugs, King Faisal College, Al-Ahasa, Saudi Arabia
Tel +966 541444922
E mail [email protected]
Summary: Obstructive sleep apnea (OSA) is characterised by frequent episodes of partial or full obstruction of the airway throughout sleep inflicting repeated episodes of apnea. OSA is extra prevalent in middle-aged and older adults. OSA is related to quite a few ocular manifestations, together with retinal manifestations. Literature highlighted the clear affiliation between OSA and quite a few ocular circumstances together with glaucoma and papilledema. This complete and narrative overview goals to summarize up-to-date scientific analysis in regards to the affiliation of OSA and vascular circumstances that have an effect on the retina. OSA is related to the central serous chorioretinopathy (CSC), retinal vein occlusion (RVO), hypertensive retinopathy (HTRP) and improvement of diabetic retinopathy (DR). Sympathetic activation, hypoxia, and hormonal dysregulation all result in severe retinal vascular circumstances that can worsen OSA sufferers’ high quality of life. You will need to refer sufferers with newly recognized OSA to an ophthalmology clinic for the suitable check.
Key phrases: obstructive sleep apnea, central retinal vein occlusion, hypertensive retinopathy, diabetic retinopathy, central serous chorioretinopathy
What’s Obstructive Sleep Apnea?
Obstructive sleep apnea (OSA) is characterised by repeated episodes of partial and full obstruction of the airway throughout sleep, leading to recurrent apnea and hypopnea.1,2 Because of poor high quality of sleeping, OSA related to extreme daytime sleepiness occurred in 6% of males and 4% of girls with OSA.1 In keeping with Franklin KA, Lindberg E of their epidemiological research of OSA, eleven revealed research estimated that the prevalence of obstructive sleep apnea to be 22% in males (vary, 9–37%) and 17% (vary, 4–50%) in girls.1
Systemic Response to OSA
OSA leads to hypoxemia and hypercapnia, which in flip result in enhanced sympathetic vasoconstrictor exercise and systemic hypertension. It’s related to quite a few cardiovascular problems, akin to myocardial ischemia, arrhythmias, and congestive coronary heart failure,3 in addition to different life-threatening incidents, akin to motorized vehicle crashes (Figure 1).4
Determine 1 Signs of OSA and underlying mechanism.
Severity of OSA
OSA severity is estimated with apnea–hypopnea index (AHI). AHI which measures the variety of apnea or hypopnea per hour throughout sleep. OSA is outlined when the AHI is ≥5. OSA thought of to be extreme if AHI <30 (Table 1).1
Desk 1 Severity of OSA In keeping with AHI (Apnea Hypo Apnea Index)
Threat Elements of OSA
The prevalence will increase with age, in addition to elevated physique mass index, waist-to-hip ratio, and neck circumference. Furthermore, different associations play an vital function within the improvement of sleep apnea, examples of which embrace abnormalities in mandibular or maxillary measurement and place, slim nasal cavities, and enlarged tonsils. Moreover, the elevated threat of OSA amongst households with OSA sufferers suggests a genetic disposition to the dysfunction.5 Reasonable to extreme types of OSA (AHI ≥15) are prevalent amongst women and men aged between thirty- and 70-year previous at percentages of 13% and 6%, respectively.6
OSA and Ocular Problems
OSA is related to quite a few ocular problems, together with floppy eyelid syndrome (FES),7 non-arteritic anterior ischemic optic neuropathy,7 glaucoma,8,9 papilledema,10 central serous chorioretinopathy CSC,11 and central retinal vein occlusions (CRVOs).12 Owing to its excessive oxygen consumption, the retina is among the most metabolically energetic tissues within the human physique. Subsequently, the retina usually manifests modifications secondary to hypoxic problems like OSA sooner than different ocular manifestations within the illness course.13
Retinal vascular problems characterize a considerable financial burden to healthcare methods. In 2019, Moshfeghi anticipated diabetic retinopathy alone to value the US healthcare system $4.5 billion in 2020.14 It’s of paramount significance to acknowledge that the affiliation between sight-threatening retinal problems and OSA is helpful not just for the lower of financial burdens but additionally for the preservation of the sufferers’ visible perform as this is able to in flip enhance OSA sufferers’ high quality of life.
This following overview is directed at ophthalmologists, and its goal is to debate the proposed mechanism concerned within the pathogenesis of retinal vascular manifestation associations and OSA. To search out the related papers, a search was carried out on PubMed and Google Scholar. The key phrases have been as follows: sleep apnea, obstructive sleep apnea, apnea–hypopnea neuropathy, central retinal vein occlusion, diabetic retinopathy, hypertensive retinopathy and central serous chorioretinopathy.
Diabetic Retinopathy and OSA
Diabetes mellitus is acknowledged as a severe public well being concern with a destructive main impression on human life and healthcare methods. Globally, 1 in 11 adults has diabetes mellitus (DM) (90% is having sort 2 diabetes mellitus).15 Furthermore, round one-third of sufferers with diabetes mellitus are estimated to have diabetic retinopathy, with one-third of these having extreme non-proliferative diabetic retinopathy (NPDR).16 A major affiliation between diabetic retinopathy and OSA has been famous within the literature.
Literature describes the connection between OSA and DM as two-way, as OSA might improve the chance of growing diabetes and diabetes is a threat issue for growing OSA. A research of 360,250 sufferers has discovered that the ratio of the incidence of OSA in sufferers with sort 2 DM in contrast with the incidence of OSA in nondiabetics is 1.48 (P < 0.001).17 On the similar time, of their meta-analysis of OSA and DR, Zhu et al discover that having OSA is considerably related to an elevated threat of DR.18
Apnea–Hypopnea Index as an Indicator of DR Development
The severity of OSA is classed in keeping with the Apnea–Hypopnea Index (AHI) worth, with an AHI worth of 5–15 thought of delicate, an AHI worth of 15–30 thought of average and an AHI worth ≥30 thought of extreme Table 1.19 Research reveal that the rise within the variety of apneic and hypoxic occasions per sleep hour is positively correlated with the development of non-proliferative DR into proliferative DR.20 Nevertheless, the AHI just isn’t the one indicator of DR development in OSA; a drop within the imply SpO2 of under 90% has additionally been noticed to be positively correlated with improvement of diabetic macular edema.20
Pathogenesis of DR and OSA
It’s hypothesized that dysregulation of circadian locomotor output cycles kaput (CLOCK) genes is straight associated to the pathogenesis of DR in sufferers with sort 2 DM.21 CLOCK genes play an important function within the coordination of circadian metabolism and homeostasis. A possible mechanism underlying elevated charges of neovascularization in OSA is a rise within the retinal vascular endothelial development issue expression on account of hypoxia-induced upregulation of the CLOCK genes.21
Steady Constructive Airway Strain Stops the Development DR in OSA
Steady constructive airway strain (CPAP) is often indicated in average and extreme OSA. It has been noticed that CPAP improves sleep high quality and reduces daytime sleepiness and fatigue together with lowering mortality and morbidities related to OSA.19 Research reveal that OSA sufferers handled with CPAP early have a considerably decrease prevalence of retinopathy in comparison with those that weren’t handled (OR 0.54, P=0.04).22 Though early remedy with CPAP improves the anatomical outcomes in sufferers with OSA, retinal nerve fiber layer thickness, and macular thickness, enchancment in visible capabilities of the attention just isn’t noticed.23 This means that the function of CPAP is to cease the development of DR in OSA sufferers, which could assist the usual DR remedy obtain the utmost therapeutic purpose.23
CRVO and OSA
Literature on CRVO and OSA Affiliation
Epidemiological research contemplate CRVO the second most typical reason for blindness from vascular illness within the retina, the primary most typical trigger being DR.24 Leroux les Jardins et al25 report three instances of RVO with OSA. Since then, an affiliation between RVO and OSA has been nicely noticed in related literature. Notably, by way of screening RVO sufferers with polysomnography, a potential and managed research has concluded that there’s a excessive OSA prevalence amongst mentioned sufferers and has sequentially instructed that OSA is a possible threat issue for RVO.26 Wan et al discovered that OSA incidence was remarkably elevated within the RVO sufferers evaluating with the management group.27 Wang et al discovered the common AHI and was considerably larger in CRVO sufferers (AHI: 13.86±8.63).28
Mechanisms of CRVO and OSA Affiliation
Mechanisms for this correlation derive from the impact of OSA on blood movement autoregulation and microvasculature. Hypertension is related to OSA and is called a threat issue for CRVO.4 Moreover, the hypercoagulable state following sluggish retinal blood movement in OSA secondary to hypoxemia and nocturnal intracranial strain elevations has been instructed to play a key function in rising the chances of CRVO.29 Final however not least, elevated sympathetic activation, peripheral vasoconstriction, oxidative stress, and endothelial harm on account of hypoxia episodes in sufferers with OSA have been postulated as essential within the improvement of CRVO.27
HTRP and OSA
Hypertension is a well known main threat issue for heart problems and all-cause mortality worldwide, with a worldwide burden of 1.38 billion individuals (31.1% of grownup inhabitants) in 2010.30 About 83.6% of whole hypertensive sufferers have been discovered to have HTRP, as recorded by Kabedi et al (grade 1: 42.1%; grade 2: 11.3%; grade 3: 23.3%; grade 4: 6.9%).31 A research by Viren et al estimates that 30–40% of hypertensive sufferers have OSA and 50% of OSA sufferers are hypertensive.32
AHI as a Predictor of Retinal Arteriolar Modifications
In a potential research of the ocular fundus, sufferers with extreme OSA (as outlined by AHI ≥20 and hypoxic burden ≥10%) have been 3 times extra more likely to have retinal vascular modifications according to delicate HTRP, akin to arteriolar narrowing, arteriolar sclerosis, and arteriovenous nicking. Nevertheless, after adjusting for hypertension as a confounder, arteriolar modifications remained extra frequent amongst sufferers with larger AHI (p = 0.04). In conclusion, AHI > 40 doubles the chance of retinal vascular modifications impartial of blood strain measurement.33 Moreover, Jessica Y. et al concluded that there’s a vital inverse affiliation between AHI and static markers of retinal arteriolar narrowing, akin to arterio-venous ratio (p=0.008) and central retinal arteriolar equal (p=0.016), no matter imply arterial strain.34 Such findings might not have been according to the speculation that AHI as a predictor of retinal arteriolar modifications. Nevertheless, regardless of this limitation, we imagine that additional research exploring the affiliation between the 2 are of paramount significance.
Proposed Mechanism of Hypertensive Retinopathy in OSA
OSA results in a rise in systemic blood strain by means of numerous mechanisms. A possible however not exhaustive listing of examples contains activation of the renin-angiotensin-aldosterone system, decreased stimulation of pulmonary stretch receptors, elevated ranges of endothelin-1, and bouts of sympathetic exercise attributable to nocturnal hypoxia and exacerbated by speedy eye motion.35 Numerous research of topics at excessive altitude have described totally different ocular modifications on fundus images, akin to retinal hemorrhages, cotton wool spots, and optic disc edema. Subsequently, it’s hypothesized that hypoxia blunts autoregulation and promotes compensatory mechanisms in retinal vasculature.36
CSC and OSA
CSC is an ocular illness characterised by decompensation of the retinal pigment epithelium and hyperpermeability of the choroidal vasculature, leading to neuroretinal detachment. An incidence of 10 per 100,000 males and a couple of per 100,000 girls is reported by Xie et al, 2008.36 Sufferers affected by CSC are sometimes offered with central scotoma, micropsia, metamorphopsia, or lack of central imaginative and prescient.37
Literature on CSC and OSA Affiliation
A retrospective case-controlled research carried out by Leveque et al concludes that the chance of OSA is considerably larger in CSC sufferers than in management topics (odds ratio = 3.67; 95% CI: 1.02, 13.14; P = 0.046). Within the research, 17 (58.6%) out of 29 CSC sufferers had an elevated threat for OSA in comparison with 9 (31.0%) of the 29 management topics. Nevertheless, potential limitations contain the implementation of the Berlin questionnaire, a self-report software with a constructive predictive worth of 89%, a sensitivity of 86 and a specificity of 77%, versus the golden customary of PSG.37
Equally, Kloos et al screened CSC sufferers for the chance of OSA with the Epworth Sleep Scale (sensitivity = 66% and specificity = 48% at an Epworth sleep scale rating >10), adopted by PSG. Kloos et al report that 22% of CSC sufferers have been discovered to have OSA, which, they cite, is larger than the final inhabitants.11 Conversely, a better prevalence of OSA based mostly on newer epidemiologic knowledge might not have been taken under consideration.
In distinction, Frank et al didn’t detect a statistically vital affiliation between CSC and OSA of their research, which managed for BMI and used a bigger cohort of sufferers. This means that earlier outcomes reported by Brodie et al might have been attributed to the confounder of BMI.38 Nevertheless, an affiliation between CSC and OSA has been established in newer research. For instance, a nationwide population-based research with the Taiwan Nationwide Well being Insurance coverage Database has recognized 10,753 OSA sufferers and 322,590 management topics and confirmed that, between the 2, the incidence of CSC was considerably larger in OSA (adjusted incident price ratio for possible SA: 1.2 [95% CI: 1.1–1.4], P < 0.0001).39 Equally, Pan et al queried over 59 million OSA sufferers and recognized these with a extra restrictive definition of OSA (sufferers who had undergone a sleep research and had a document of receiving a CPAP gadget) and concluded that the chance of CSC is considerably elevated with OSA analysis (HR = 1.081, P < 0.033).40
Proposed Mechanism of CSC in OSA
Elevated ranges of epinephrine, norepinephrine and corticosteroids are hypothesized to be the primary pathophysiology underlying the affiliation between CSC and OSA. Elevated catecholamines are considered as a result of intermittent asphyxia and sudden arousal from sleep. Equally, pulsatile corticosteroids launch happens throughout nocturnal arousals, and corticosteroid ranges are believed to be elevated in sleep-deprived sufferers. Moreover, norepinephrine stimulates corticotrophin and results in the additive impact of additional cortisol launch.37
CPAP and CSC
A case report on bilateral CSC that resolved quickly after beginning CPAP machine remedy additional helps the proposed affiliation between CSC and OSA.41 Moreover, Liu et al have concluded that suspected OSA sufferers who acquired CPAP had a considerably decreased CSC incidence price, versus the non-CPAP group.39
OSA is frequent, and its prevalence is climbing with the elevated prevalence of weight problems, alongside different threat elements. OSA continues to be underdiagnosed and solely 15% of those that are symptomatic obtain OSA remedy. There’s a rising physique of literature displaying a relationship between OSA and numerous sight-threatening ocular circumstances, together with retinal vascular manifestation. Sympathetic activation, hypoxia, and hormonal dysregulation all result in quite a few retinal vascular circumstances that can worsen OSA sufferers’ high quality of life. Early detection with applicable intervention of any retinal vascular situation can lower the burden of OSA. This necessitates an early referral to bear sleep research for these with poorly managed hypertensive retinopathy and non-arteritic anterior ischemic optic neuropathy.
OSA, obstructive sleep apnea; CRVO, central retinal vein occlusion; HTR, hypertensive retinopathy; DR, deiabetic retinopathy; CSC, central serous chorioretinopathy; AHI, apnea hypo apnea index; DM, diabetes mellitus; CPAP, steady constructive airway strain.
The authors report no conflicts of curiosity for this work.
1. Franklin KA, Lindberg E. Obstructive sleep apnea is a typical dysfunction within the population-a overview on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311–1322. doi:10.3978/j.issn.2072-1439.2015.06.11
2. Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP. Pathophysiology of sleep apnea [published correction appears in Physiol Rev.2010 Apr; 90(2):797–8]. Physiol Rev. 2010;90(1):47–112. doi:10.1152/physrev.00043.2008
3. Dorasamy P. Obstructive sleep apnea and cardiovascular threat. Ther Clin Threat Manag. 2007;3(6):1105–1111.
4. Tregear S, Reston J, Schoelles Okay, Phillips B, Obstructive sleep apnea and threat of motorized vehicle crash: systematic overview and meta-analysis. J Clin Sleep Med. 2009;5(6):573–581. doi:10.5664/jcsm.27662
5. Younger T, Skatrud J, Peppard PE. Threat elements for obstructive sleep apnea in adults. JAMA. 2004;291(16):2013–2016. doi:10.1001/jama.291.16
6. Rana D, Torrilus C, Ahmad W, et al. Obstructive sleep apnea and cardiovascular morbidities: a overview article. Cureus. 2020;12(9):e10424. doi:10.7759/cureus.10424
7. Palombi Okay, Renard E, Levy P, et al., Non-arteritic anterior ischaemic optic neuropathy is sort of systematically related to obstructive sleep apnoea. Br J Ophthalmol. 2006;90(7):879–882. doi:10.1136/bjo.2005.087452
8. Mojon DS, Hess CW, Goldblum D, et al. Excessive prevalence of glaucoma in sufferers with sleep apnea syndrome. Ophthalmology. 1999;106(5):1009–1012. doi:10.1016/S0161-6420(99)00525-4
9. Sergi M, Salerno DE, Rizzi M, et al. Prevalence of regular stress glaucoma in obstructive sleep apnea syndrome sufferers. J Glaucoma. 2007;16(1):42–46. doi:10.1097/01.ijg.0000243472.51461.24
10. Purvin VA, Kawasaki A, Yee RD. Papilledema and obstructive sleep apnea syndrome. Arch Ophthalmol. 2000;118(12):1626–1630. doi:10.1001/archopht.118.12.1626
11. Kloos P, Laube I, Thoelen A. Obstructive sleep apnea in sufferers with central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol. 2008;246(9):1225–1228. doi:10.1007/s00417-008-0837-0
12. Shah SM, Bakri SJ. Obstructive sleep apnea analysis in retinal vein occlusion sufferers: a chance for multidisciplinary care? Can J Ophthalmol. 2020;55(4):284–285. doi:10.1016/j.jcjo.2020.03.004
13. Wang XY, Wang S, Liu X, et al. Retinal vascular morphological modifications in sufferers with extraordinarily extreme obstructive sleep apnea syndrome. Chin Med J (Engl). 2017;130(7):805–810. doi:10.4103/0366-6999.202728
14. Moshfeghi A. Evaluating the social prices of blindness from AMD.
15. Sapra A, Bhandari P. Diabetes mellitus. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Jan, 2020 [
16. Lee R, Wong TY, Sabanayagam C, Epidemiology of diabetic retinopathy, diabetic macular edema and associated imaginative and prescient loss. Eye Imaginative and prescient. 2015;2(1):17. doi:10.1186/s40662-015-0026-2
17. Subramanian A, Adderley NJ, Tracy A, et al. Threat of incident obstructive sleep apnea amongst sufferers with sort 2 diabetes. Diabetes Care. 2019;42(5):954–963.
18. Zhu Z, Zhang F, Liu Y, et al. Relationship of obstructive sleep apnoea with diabetic retinopathy: a meta-analysis. Biomed Res Int. 2017;2017:4737064. doi:10.1155/2017/4737064
19. Epstein LJ, Kristo D, Strollo PJ
20. Shiba T, Sato Y, Takahashi M. Relationship between diabetic retinopathy and sleep-disordered respiration. Am J Ophthalmol. 2009;147(6):1017–1021. doi:10.1016/j.ajo.2008.12.027
21. Kusunose N, Akamine T, Kobayashi Y, et al. Contribution of the clock gene DEC2 to VEGF mRNA upregulation by modulation of HIF1a protein ranges in hypoxic MIO-M1 cells, a human cell line of retinal glial (Müller) cells. Jpn J Ophthalmol. 2018;62(6):677–685.
22. Nishimura A, Kasai T, Kikuno S, et al. Apnea hypopnea index throughout speedy eye motion sleep with diabetic retinopathy in sufferers with sort 2 diabetes. J Clin Endocrinol Metab. 2019;104(6):2075–2082.
23. Lin PW, Lin HC, Friedman M, et al. Results of CPAP for sufferers with OSA on visible sensitivity and retinal thickness. Sleep Med. 2020;67:156–163. doi:10.1016/j.sleep.2019.10.019
24. Huon LK, Liu SY, Camacho M, Guilleminault C, The affiliation between ophthalmologic illnesses and obstructive sleep apnea: a scientific overview and meta-analysis. Sleep Breath. 2016;20(4):1145–1154. doi:10.1007/s11325-016-1358-4
25. Leroux Les Jardins G, Glacet-Bernard A, Lasry S, Housset B, Coscas G, Soubrane G, Retinal vein occlusion and obstructive sleep apnea syndrome. J Fr Ophtalmol. 2009;32(6):420–424. doi:10.1016/j.jfo.2009.04.012
26. Felfeli T, Alon R, Adel FA. Screening for obstructive sleep apnea amongst sufferers with retinal vein occlusion. Can J Ophthalmol. 2020;10:1016.
27. Wan W, Wu Z, Lu J, et al. Obstructive sleep apnea is expounded with the chance of retinal vein occlusion. Nat Sci Sleep. 2021;13:273–281. doi:10.2147/NSS.S290583
28. Wang YH, Zhang P, Chen L, et al. Correlation between obstructive sleep apnea and central retinal vein occlusion. Int J Ophthalmol. 2019;12(10):1634–1636. doi:10.18240/ijo.2019.10.17
29. Grover DP, Obstructive sleep apnea and ocular problems. Curr Opin Ophthalmol. 2010;21(6):454–458. doi:10.1097/ICU.0b013e32833f00dc
30. mills KT, Stefanescu A, He J. The worldwide epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223–237. doi:10.1038/s41581-019-0244-2
31. Kabedi NN, Mwanza JC, Lepira FB, Kayembe TK, Kayembe DL. Hypertensive retinopathy and its affiliation with cardiovascular, renal and cerebrovascular morbidity in Congolese sufferers. Cardiovasc J Afr. 2014;25(5):228–232. doi:10.5830/CVJA-2014-045
32. Viren SK, White DP, Amin R, et al. Sleep apnea and heart problems: an American Coronary heart Affiliation/American School of Cardiology basis scientific assertion from the American coronary heart affiliation council for hypertension analysis skilled schooling committee, council on scientific cardiology, stroke council, and council on cardiovascular nursing. J Am Coll Cardiol. 2008;52(8):686–717. doi:10.1016/j.jacc.2008.05.002
33. Fraser CL, Bliwise DL, Newman NJ, et al. A potential photographic research of the ocular fundus in obstructive sleep apnea. J Neuroophthalmol. 2013;33(3):241–246. doi:10.1097/WNO.0b013e318290194f
34. Tong JY, Golzan M, Georgevsky D, et al. Quantitative retinal vascular modifications in obstructive sleep apnea. Am J Ophthalmol. 2017;182:72–80. ISSN 0002-9394. doi:10.1016/j.ajo.2017.07.012
35. Kario Okay. Obstructive sleep apnea syndrome and hypertension: mechanism of the linkage and 24-h blood strain management. Hypertens Res. 2009;32(7):537–541. doi:10.1038/hr.2009.73
36. Xie Y, Wang N. The attention and excessive altitude. In: Wang N, editor. Integrative Ophthalmology. Advances in Visible Science and Eye Illnesses. Vol. 3. Singapore: Springer; 2020. doi:10.1007/978-981-13-7896-6_15
37. Kitzmann AS, Pulido JS, Diehl NN, Hodge DO, Burke JP. The incidence of central serous chorioretinopathy in Olmsted County, Minnesota, 1980–2002. Ophthalmology. 2008;115(1):169–173. doi:10.1016/j.ophtha.2007.02.032
38. Brodie FL, Charlson ES, Aleman TS, et al. Obstructive sleep apnea and central serous chorioretinopathy. Retina. 2015;35(2):238–243. doi:10.1097/IAE.0000000000000326
39. Liu PK, Chang YC, Tai MH, et al. The affiliation between central serous chorioretinopathy and sleep apnea: a Nationwide Inhabitants-Primarily based Research. Retina. 2020;40(10):2034–2044. doi:10.1097/iae.0000000000002702
40. Pan CK, Vail D, Bhattacharya J, Cao M, Mruthyunjaya P. The impact of obstructive sleep apnea on absolute threat of central serous chorioretinopathy. Am J Ophthalmol. 2020;218:148–155. doi:10.1016/j.ajo.2020.05.040
41. Jain AK, Kaines A, Schwartz S. Bilateral central serous chorioretinopathy resolving quickly with remedy for obstructive sleep apnea. Graefes Arch Clin Exp Ophthalmol. 2010;248(7):1037–1039. doi:10.1007/s00417-009-1257-5