The Pathophysiological Association Between Obstructive Sleep Apnea and Glaucoma: A Current Update

Glaucoma is a chronic, progressive optic neuropathy and the second leading cause of irreversible blindness worldwide. Although elevated intraocular pressure (IOP) remains the principal modifiable risk factor, it is neither necessary nor sufficient for disease development. The literature indicates that systemic conditions such as obstructive sleep apnea (OSA) may contribute to its pathogenesis. The pathophysiology of glaucoma is supported by several theories, primarily the mechanical and vascular theories. This review describes the pathophysiological links between OSA and glaucoma considering current theories. The principal connecting mechanism appears to be chronic intermittent hypoxia and reduced ocular perfusion pressure, which trigger optic nerve head hypoxia, oxidative stress, and biomechanical remodeling of the lamina cribrosa. These processes interact within a vicious cycle that progressively compromises the metabolic support of optic nerve axons. The mechanisms described are particularly relevant to normal-tension glaucoma, which may be associated with OSA. Retinal nerve fiber layer thinning appears among the earliest markers of optic nerve vulnerability, whereas IOP and visual field changes are more variable. These observations underscore the clinical relevance of the OSA-glaucoma relationship and support a multidisciplinary approach incorporating routine ophthalmic screening for subclinical optic nerve damage.