Saturday, July 08, 2017

Severe Sleep Apnea & Retinal Nerve Fiber Layer

In severe OSA the retinal nerve fiber layer had reduced thickness.- JR

 2016 Apr 18;16:40. doi: 10.1186/s12886-016-0216-2.

Assessment of the retinal nerve fiber layer in individuals with obstructive sleep apnea.



The effect of obstructive sleep apnea (OSA) syndrome in the peripapillary retinal nerve fiber layer (RNFL) thicknesses remains unclear. The purpose of this study was to assess RNFL measurements acquired using scanning laser polarimetry (SLP) and optical coherence tomography (OCT) in patients with OSA.


The sample of this cross-sectional study included 40 OSA patients and 45 age-matched controls, consecutively and prospectively selected. All participants underwent at least one reliable standard automated perimetry (SAP) test, while RNFL measurements were obtained using the SLP and OCT. The OSA group was divided into 3 sub-groups based on the apnea/hypopnea index (AHI): mild, moderate, or severe OSA. SAP, SLP, and OCT outcomes were compared between the control and OSA groups. The relationship between AHI and RNFL parameters was also evaluated.


Age was not different between both groups. Mean deviation of SAP was -0.47 ± 0.9 dB and -1.43 ± 2.3 dB in the control and OSA groups, respectively (p = 0.01). RNFL thickness measured with OCT was similar between groups. OSA patients showed increased nerve fiber indicator (NFI; 20.9 ± 7.9 versus 16.42 ± 7.82; p = 0.01) and decreased superior average (59.74 ± 10.35 versus 63.73 ± 6.58; p = 0.03) obtained with SLP compared with healthy individuals. In the total sample, NFI and AHI were moderately correlated (r = 0.358; p = 0.001). In severe OSA subjects (n = 22), NFI and AHI had a Spearman correlation coefficient of 0.44 (p = 0.04).


RNFL thickness measured with OCT did not differ significantly between groups. Severe OSA was related to a reduction of the RNFL thickness assessed by SLP.


Obstructive sleep apnea; Optic nerve head; Optical coherence tomography; Retinal nerve fiber layer; Scanning laser polarimetry
[Indexed for MEDLINE] 
Free PMC Article

Sleep Apnea and the Retina

Retinal blood vessel abnormalities noted in sleep apnea. Another good reason to seek treatment. - JR

 2017 Apr 5;130(7):805-810.

Retinal Vascular Morphological Changes in Patients with Extremely Severe Obstructive Sleep Apnea Syndrome.

Wang XY1Wang S2Liu X3Ding X1Li M2Han DM1.



Obstructive sleep apnea syndrome (OSAS) has been shown to generate hypertension and endothelial dysfunction. Retinal vessel is the only vessel that can be observed directly and noninvasively; retinal vascular abnormalities can serve as a predictive marker for the occurrence, clinical course, and prognosis of cardiovascular and cerebrovascular diseases. The objective of this study was to identify the effect of OSAS severity on the morphological changes of retinal vessels.


Adult patients complained of snoring were included in this study. The patients' general information, polysomnography, and fundus photography parameters including central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole-to-venule ratio (AVR) were collected. Patients were divided into four groups according to their apnea-hypopnea index (AHI) results: Group I, AHI ≤5/h; Group II, 5/h < AHI ≤30/h; Group III, 30/h < AHI ≤60/h; and Group IV, AHI> 60/h.


A total of 133 patients were included in this study with 111 males (83.5%) and 22 females (16.5%). Mean age was 41.6 ± 9.9 years, and the mean body mass index was 28.1 ± 4.0 kg/m2. AHI ranged between 0 and 130.8/h with a mean of 39.1 ± 30.7/h. There were 24, 34, 35, and 40 patients in Group I, Group II, Group III, and Group IV, respectively. Significant differences were found for AHI (F = 388.368, P< 0.001), minimal pulse oxygen saturation (F = 91.902, P< 0.001), and arousal index (F = 31.014, P< 0.001) among four groups; no significant differences were found for CRAE (F = 0.460, P = 0.599) and CRVE (F = 0.404, P = 0.586) among groups; there were significant differences for AVR between Group I and Group IV (63.6 ± 5.1% vs. 67.2 ± 5.5%, P = 0.010) Group II and Group IV (64.5 ± 6.0% vs. 67.2 ± 5.5%, P = 0.030), and Group III and Group IV (64.7 ± 4.1% vs. 67.2 ± 5.5%, P = 0.043). A main group-by-AHI effect was found on the AVR: patients with higher AHI showed higher AVR results (r = 0.225, P = 0.009). Multivariate logistic regression analysis was used for multi-variable factors. A group-by-age effect was found on the AVR: younger patients showed higher AVR results (β = -0.001, P = 0.020).


This study indicated that increased AVR of retinal vessel can be observed in extremely severe OSAS patients. For patients with OSAS, c.
[Indexed for MEDLINE] 
Free PMC Article

Retinal Vein Stroke? Sleep Apnea in 10%

Central retinal vein occlusion can be caused by many medical problems. 
10 % have sleep apnea in this series.

 2017 Apr 24. 




To investigate whether the results of early tests for hypercoagulability are correlated with the development of central retinal vein occlusion risk factors later in life and to evaluate the necessity of these tests in younger patients.


This was a retrospective, observational case series. From January 1995 to December 2014, 55 patients aged below 56 years with central retinal vein occlusion (CRVO) were enrolled in the study. Laboratory evaluations for homocysteine, activated protein C resistance, protein C activity, protein S activity, antithrombin III activity, antiphospholipid antibodies, and anticardiolipin antibodies were obtained at the onset of CRVO. After 24 to 205 months, the presence of risk factors for CRVO such as hypertension, obesity, hyperlipidemia, diabetes mellitus, sleep apnea, and glaucoma was determined. Bilateral correlation and logistic regression were performed to determine the correlations between the results of the initial laboratory tests and the diagnosis of CRVO risk factors.


The median follow-up was 168.5 months. Five patients completed at least 24 months of follow-up, 9 patients completed at least 5 years, and 36 patients completed at least 10 years. Five patients had no or less than 24 months' follow-up. Fourteen of 50 patients (28%) had at least one positive test result at the onset of CRVO. At the end of follow-up, 11 patients had been diagnosed with obesity (22%), 29 with hypertension (58%), 21 with hyperlipidemia (42%), 24 with diabetes (8%), 5 with sleep apnea (10%), and 8 with glaucoma (16%). Among 36 patients with a minimum 10 years' follow-up, 30 (83%) developed at least one common risk factor, and none experienced any thromboembolic events. There were no correlations between test results and the diagnosis of any risk factors in patients with a minimum of 2, 5, or 10 years' follow-up (P > 0.05).


The results of laboratory tests evaluating hypercoagulability in young patients with CRVO are not correlated with later-developed commonly known risk factors. Many of the common risk factors were present by the end of the study, suggesting that they still remain the core etiology for the disease. The value of the thrombophilic tests is brought into question, as none of the patients demonstrated further clotting or any unusual thrombi with long-term follow-up.

Monday, July 03, 2017

Add Academy to ECW or other EMR to send orders for Sleep & EEG Testing Outpatient for Kids and Adults in Texas

Dear Colleague,

Sleep referrals are complex these days.

·      Home sleep test?  In-Lab Test?
·      Adult patients fail with home tests.
·      Patients fail home AUTO CPAP.

For 10 years Academy and its physician experts have welcomed infants and children of all ages & complexity.   Our affiliated Houston AND San Antonio  specialists can be seen HERE.

What can you do for your patients and to make the office flow smoothly?

Optimize your EMR function by adding Academy Diagnostics:

  • ·      Academy Diagnostics will help your patients and your practice access gold-standard care.
  • ·      Academy can save you and your MA time.

In eClinicalWorks  or another EMR, add Academy Diagnostics to seamlessly refer your sleep and EEG procedures via P2P or other systems, by the following:

1)   Add us to your Referring providers

a.     Last Name = Academy
b.    First Name = Diagnostics
c.     Specialty = Sleep Medicine

Academy Diagnostics - Houston

Academy Diagnostics – San Antonio


Phone: 832-659-0248
 Fax: 832-659-0261

SAN ANTONIO, TX  78229-3355

Phone: 210-616-9500
Fax: 210-616-0400

NPI: 1093112518

NPI: 1861615163

Taxonomy 261QS1200X

Taxonomy 261QS1200X

2)    You can also:

  •     create other custom specialties and entries for special procedures: EEG lab, e.g. neurophysiology.
  •        add Academy under “Labs” if this works well for your workflow.

Please notify us if you have questions about procedure codes.

Our PDF of order forms can be found HERE

Academy Diagnostics Staff

 Illustration of Linked Procedures  - (Sleep and EEG/Neuro)


PEDIATRIC SLEEP PROCEDURES (under 6) Newborns can have sleep studies by day. 

o 95782 Pediatric Diagnostic Polysomnogram (Sleep Study)
o 95783 Pediatric CPAP Titration (If Polysomnogram is positive for OSA or a previous study was performed and results are available)

o 95810 Diagnostic Polysomnogram (Sleep Study) (HST if required by insurance)
o 95811 CPAP Titration (If polysomnogram is positive for OSA or a previous study was performed and results are available.)
o 95811 Split Night Study (Treatment portion to be performed only if the patient meets criteria.)
o 95805 Multiple Sleep Latency Test (MSLT) following a Diagnostic Polysomnogram
o 95805 Maintenance of Wakefulness Test (MWT)

HOME Sleep Testing - Adults

oCPT Code 95806 Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow and respiratory effort.
  oHCPCS Code  G0399 Home sleep test with Type III portable monitor, unattended; minimum of four channels: two respiratory movement/airflow, one ECG/heart rate and one oxygen saturation

Sample Linked DIAGNOSIS Must indicate at least one qualifying diagnosis:
o G47.33 Obstructive Sleep Apnea
o G47.37 Central Sleep Apnea
o E66.01 Obesity Hypoventilation Syndrome
o G47.61 Periodic Limb Movement Disorder
o F51.8 Sleep Related Movement Disorders, unspecifed
o G47.419 Narcolepsy
o F51.13 Organic Hypersomnia/EDS
o G47.54 Parasomnias
o G47.20 Disruption of 24 hr Sleep/Wake Cycle Other Qualifying Code ___________________

PRE-TEST ESSENTIAL Data for Adults  PRE-EXISTING CONDITIONS NOTE: Please indicate if the following Are Applicable

o E66.01 Morbid Obesity (Needs additional diagnosis)
o Pulmonary Disease (Respiratory Failure, COPD, Hypoxemia) 
oNeurologic OR Neuromuscular Disease (Epilepsy, Dementia, ALS, Parkinson’s, etc.)
o Significant Cardiac Disease (CHF, Atrial Fibrillation, Pulmonary Hypertension, Arrhythmias) 
oAll other conditions  ______________________

PRE-Test Essential Data for Adults

Ht:________________ Wt:________________ Neck Circumference________ BMI_________
*Epworth Sleepiness Scale (ESS = 10 or more)

Neuro-Diagnostics - EEG

o Routine EEG (Greater than one hour)
o Extended Video EEG Monitoring (Greater than 14 hours)

Sample Diagnoses:
R40.4 Transient alteration of awareness
R55 Syncope and collapse
G40.389 Epilepsy, unspecified
R56.9 Other Convulsions (e.g. seizure NOS)
R56 Convulsions