• Letters

    Thoughts From Your Colleagues

    Ask About OSA

    I write in response to “Obstructive Sleep Apnea and the Eye: The Ophthalmologist's Role” (Clinical Update, February). Eighteen million Americans suffer from obstructive sleep apnea (OSA), and many of them use continuous positive airway pressure (CPAP) therapy; compliance after 24 months has been as high as 83 percent.

    Most of these patients are obese, and, without CPAP, they find that apnea is noticeably reduced when they sleep facedown. The continual rubbing of the eyelids against the pillow accounts for the increased rate of floppy eyelid syndrome (FES), keratoconus, and adnexal disorders among these patients. Eventually, they are prescribed a CPAP device to help them sleep. But this means the nightly use of a mask that may leak and pump a continuous flow of air into both eyes.

    OSA can lead to chronic fatigue, headaches, trouble concentrating, depression, and irritability, and CPAP eases these symptoms. This explains why these patients have such a high compliance rate, despite the fact that their eyes are giving them a lot more trouble than before treatment.

    In the eye clinic, we get many obese patients with red, itchy, asymmetrical follicular chronic conjunctivitis and blepharitis that hardly improve with treatment. However, in taking a patient’s history, clinicians usually do not ask about OSA and the use of CPAP. But even when asked what treatments they are on, patients rarely answer CPAP, as they do not regard it as a treatment.

    In my opinion, three points should be addressed by the ophthalmic community regarding OSA.

    • As with diabetes and hypertension, patients diagnosed with OSA should automatically be referred to an ophthalmologist.
    • Ophthalmologists should ask about OSA and CPAP in patients who are obese and suffer from chronic blepharitis, keratoconus, FES, snoring, or chronic fatigue.
    • CPAP mask manufacturers should enlist ophthalmologists to help assess the impact of these devices on eyes over the short, medium, and long term.

    This endeavor can only be achieved if general practitioners, endocrinologists, ophthalmologists, and other physicians work together as a team. Although the widespread use of CPAP devices is in its early days, it is a lifetime therapy and may prove to provoke more side effects than the ones we are seeing now.  

    Francisco Jover Hernando, MD  
    Jerez de la Frontera, Spain

    Office Details

    The Opinion “Distracted? Finding Focus in Spite of Technology” (February) makes a good point about placement of computer screens for medical records while examining the patient—it is overlooked by many.

    I also wanted to mention the term “waiting room.” Long ago, my office people were told to call it a “reception area.” It is not just semantics; it is a state of mind.

    I always enjoy Opinion.

    Russell T. Stodd, MD  
    Kahului, Hawaii  

    Choose Wisely—Choose Generics

    I write regarding the Academy’s “Five Things Ophthalmologists and Patients Should Question” as part of its participation in the Choosing Wisely campaign. What about a sixth idea? I propose that all ophthalmologists, or even all physicians, make a concerted effort to use generic drugs whenever possible—with the blessings of their academies, of course. In the last year or so, I have made it a priority to make this switch. I have found that the generics generally work very well, and my patients and their respective insurance companies or Medicare have saved money.

    I am attempting to reduce the cost of medical care nationally without affecting my quality of care. I believe medication costs in the United States are about one-third of a trillion dollars annually—even a small dent in that would be enormous. A big dent could completely solve our financial problem. The only victims would be the drug companies and their stockholders, of which I am one.

    David M. Shepherd, MD  
    Novi, Mich.
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