Periocular Manifestation of Obstructive Sleep Apnea as a Novel Perioperative Screening Tool

Megan Folsom,Danstan Bagenda,Huiling Pang,Brent Timperley,Kurtis Johnson,James Gigantelli,Sheila Ellis

doi:10.1007/s11695-021-05851-7

Abstract

PurposeObstructive sleep apnea (OSA) presents perioperative challenges with increased risk for complications. Floppy eyelid syndrome (FES) is associated with OSA yet has not been addressed perioperatively. The current standard for perioperative OSA screening includes assessing patient risk factors or the STOP-BANG tool, which requires an active participant. We aimed to confirm a connection between FES and OSA in presurgical patients and develop a screening method appropriate for patients with perioperative OSA risk.Materials and Methods162 presurgical pre-anesthesia clinic patients were enrolled. Screening questions determined eligibility. Those who were pregnant or aged < 19 were excluded. Control group included those with a STOP-BANG score < 3. Experimental group included those with BMI > 35 and OSA diagnosis. Examiners photographed participants’ eyes with vertical and horizontal retraction while two blinded ophthalmologists used a grading scale to review grade of eyelid laxity.ResultsDifferences in habitus, ASA score, and hypertension as a comorbidity were significant. Sensitivity of FES screening was 52% (CI 37–66%) and specificity was 56% (CI 46–66%) for reviewer 1. For reviewer 2, sensitivity was 48% (CI 28–69%) and specificity was 72% (CI 60–81%). Negative predictive value was 86% (CI 81–90) for reviewer 1 and 88% (CI 83–92%) for reviewer 2. Inter-rater agreement was moderate.ConclusionWhile specificity and sensitivity were lower than anticipated, negative predictive value was high. Given this strong negative predictive value, our findings indicate using eyelid retraction to screen for FES has perioperative clinical utility. These findings encourage further research addressing the connection of lid laxity/FES to OSA.Key Points• Aimed to investigate if a FES screening tool could identify perioperative OSA risk.• Negative predictive value for FES with OSA was 86%.• Observing periocular lid laxity has clinical utility; is feasible in any patient.Graphical abstract

Highlights

Obstructive sleep apnea (OSA) challenges anesthesiologists in perioperative settings
One patient in the non-OSA group was excluded from data analysis due to self-reported history of OSA and continuous positive airway pressure (CPAP) use
Average American Society of Anesthesiology (ASA) score was significantly higher in the OSA group (p = 0.03)

Summary

Introduction

Obstructive sleep apnea (OSA) challenges anesthesiologists in perioperative settings. Those with OSA can experience increased sensitivity to narcotics, airway complications, cardiac arrest, and anoxic brain injury, with increased risk for serious perioperative complications [1, 2]. Chan et al found that nearly 68% of patients undergoing major noncardiac surgery had unrecognized OSA with increased risk of 30-day postoperative cardiovascular complications based on preoperative oximetry sleep studies [5]. Medications used in the administration of anesthesia relax upper airway structures, leading to obstruction. They affect lung mechanics, ventilation, oxygenation, and airway protection, all of which can exacerbate OSA or cause acute airway obstruction perioperatively. Preoperatively identifying patients with or at risk for OSA can be of importance

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