Did you get the memo about CPAP and dry eye?

CPAP masks often leak and cause eye irritation by blowing air over or into the eyes. Many CPAP providers and sleep centers are surprisingly ill equipped to help their patients who suffer from CPAP-related eye irritation, including failing to refer them to an eye doctor. On the other hand, many eyecare professionals are also unaware of their patients' CPAP use.

In the Dry Eye Shop's 15 years of existence I've constantly come across a number of problems stemming from this, including:

• Many people who are not receiving any ongoing eye care may suffer from eye issues for a long time without knowing that their eye irritation or redness is caused by their CPAP mask.
• People with dry eye, blepharitis, or simply nocturnal lagophthalmos may experience a significant worsening of symptoms during CPAP use and find that their symptoms don't respond to conventional dry eye treatment.
• People who already have moderate to severe dry eye may find the effects of the CPAP mask intolerable, leaving them to choose between CPAP therapy and protecting their eyes.

Theoretically, this problem "ought" to be fixable by either adjusting the mask or switching to a different style mask. But that's just not the case. I've talked to a great many people who have tried 5 or even 10 or more CPAP masks!

So how do you, the Truly Excellent Dry Eye Doctor, help?

Solutions

It's really no different than with nocturnal lagophthalmos: When lubrication isn't enough, you need a physical barrier. It could be anything from cling film to a sleep mask to a moisture goggle. Better yet, it could be a product designed specifically for this job, such as the Quartz silicone shield.

And while nobody really wants to wear a face full of completely un-sexy gear every night, the dry eye patient in pain who also wants a proper night's sleep will be only too happy to do what it takes - if it works! (Meet Ray, by the way, one of my longtime DryEyeShop friends!) 

Which brings us to the real challenge: For some, it may be hard enough to get used to the idea of wearing a moisture goggle at night - but will that goggle even be compatible with the CPAP mask, or will they interfere with each other's seals? 

The Quartz are the most likely to be compatible, but they don't fit everyone.

The Eyeseals (pictured) does the best job blocking moving air, but it's not compatible with every CPAP. It's also going to be too large for women with very small or very narrow faces. Ray is wearing an Eyeseals - albeit a rather aged one.

This is something we deal with every day at the Dry Eye Shop... looking up people's CPAP masks and making recommendations. And taking returns and swapping things out and troubleshooting. We're also building a list of reports from patients about what is working best for them: Which moisture goggle will work with my CPAP mask? It was only after my survey had been running for quite awhile that I learned how many people are successfully using Tranquileyes moisture goggles with their CPAP, and preferring them over the other (transparent) types! I never would have guessed.

So what can you do that will make YOUR dry eye practice CPAP user-friendly?

Good practice:

• Always find out from your dry eye patients whether they use CPAP, and if so, have a conversation about the possibility that it's contributing. (Bear in mind... 22 million Americans suffer from obstructive sleep apnea.)
• Steer them back to the CPAP provider for more adjustment or an alternative mask if possible, while addressing the eye side of things.
• Do NOT assume that the CPAP provider knows anything at all about goggles to protect the eyes.
• If they are symptomatic and/or have a lot clinical signs, and they're already using suitable lubricants but not getting enough relief, tell them about moisture goggles, and maybe even our reference list for CPAP. 
• Recommend that they schedule a phone consultation with us so we can help them figure out what tool(s) might be worth trying.

Best practice!

As above, plus:

• Train a tech or optician about this issue and buy a variety of dry eye goggles to have on hand. (I don't mean that you need to sell them - but just have some available so patients can get some idea what you're talking about.) That way your dry eye patients can bring their CPAP mask in and figure out right then and there what they can use. 
• Call us when you are at your wits' end with a complicated dry eye patient who uses CPAP and nothing is working. We love troubleshooting :)
• Ask your patients to participate in our CPAP survey so other patients can get the benefit!

What does TFOS DEWS II say about CPAP and dry eye?

It's interesting, because while unquestionably a lot of patients are having issues, some of the actual studies are showing benefits to dry eye from CPAP therapy. (Is that because more sleep improves the tear film as some studies are suggesting?)

One thing the report does not mention, however, is the problem of Jones tube patients with CPAP, as in this case report where the mask was blowing air straight up the tube onto the patient's eye. Ugh. I have talked with some of these patients. In a few cases actually the most successful solution was a Tranquileyes goggle, others, strategic placement of some really good quality medical tape (never ideal, but sometimes necessary).

Anyway, here's the relevant excerpt from the Iatrogenic dry eye report, (4.5.4.1). 

Noninvasive ventilation can be defined as a ventilation modality that supports breathing without the need for intubation or surgical airway. Noninvasive ventilation has been used for the management of pediatric and adult respiratory conditions in both the emergency department and the intensive care unit, and it has gained increasing popularity in the treatment for moderate-to-severe obstructive sleep apnea hypopnea syndrome (OSAHS) [566]. Positive pressure noninvasive ventilation includes continuous positive airway pressure (CPAP) and bilevel positive airway pressure. The masks are held in place by straps around the head, and patients often complain that the masks leak air onto the ocular surface and irritate the surrounding skin [566]. There are a few studies reporting a negative effect of the short term CPAP treatment on the ocular surface of patients with OSAHS. Hayirci et al. [567] found elevated Schirmer and lower TBUT values after the CPAP therapy which was explained by its irritative properties. On the other hand, Kadyan et al. [568] reported increased TBUT values in patients with OSAHS after the application of CPAP treatment. Similar results were found by Acar et al. [569] in patients with OSAHS and floppy eye syndrome who underwent an appropriate, 18 months CPAP therapy. The authors also reported a significant decline in the corneal staining scores and a decrease of the OSDI in these patients, which can be explained by the increasing of ocular surface stability as part of the improvement of the clinical situation of floppy eye syndrome. CPAP therapy warrants awareness by physicians of the associated ocular surface problems [567]. For patients with preexisting OSD, more sophisticated CPAP devices or alternative treatment modalities should be considered, in addition to the use of topical lubricants [567].

References

[566] Hostetler MA. Use of noninvasive positive-pressure ventilation in the emergency department. Emerg Med Clin N Am 2008;26(4):929–939. viii.
[567] Hayirci E, Yagci A, Palamar M, Basoglu OK, Veral A. The effect of continuous positive airway pressure treatment for obstructive sleep apnea syndrome on the ocular surface. Cornea 2012;31(6):604–608.
[568] Kadyan A, Asghar J, Dowson L, Sandramouli S. Ocular findings in sleep apnoea patients using continuous positive airway pressure. Eye (London, England) 2010;24(5):843–850.
[569] Acar M, Firat H, Yuceege M, Ardic S. Long-term effects of PAP on ocular surface in obstructive sleep apnea syndrome. Can J Ophthalmol 2014;49(2):217–221.