In obstructive sleep apnea (OSA), the airway repeatedly narrows or closes during sleep. Breathing pauses, oxygen levels drop, and the brain briefly wakes to reopen the airway, often many times an hour. OSA is one of the factors most strongly associated with NAION in research,¹ ² ³ and it is very treatable.

For patients and families

Signs to mention to your doctor

Loud snoring, pauses in breathing that someone else notices, waking up gasping or choking, morning headaches, and feeling sleepy or tired during the day.

Screening questionnaires

These help decide who should have a sleep test. They cannot diagnose sleep apnea on their own.⁴ – STOP-Bang: eight yes/no questions: Snoring, Tiredness, Observed breathing pauses, high blood Pressure, BMI over 35, Age over 50, Neck size large, male Gender. A score of 0–2 suggests low risk of moderate-to-severe OSA; 5–8 suggests high risk; 3–4 needs more information.⁵ ⁶ – Epworth Sleepiness Scale: you rate how likely you are to doze in eight everyday situations, such as reading or riding in a car. It measures daytime sleepiness, which is common in OSA but not present in everyone who has it.⁷

Diagnosis: a sleep test

• Home sleep apnea test: a small device worn overnight at home. It is appropriate for many adults with uncomplicated symptoms suggesting moderate-to-severe OSA.⁴
• In-lab sleep study (polysomnography): the standard test, done overnight in a sleep center. It is used when a home test is negative or unclear, or when someone has significant heart or lung disease, certain nerve or muscle conditions, chronic opioid use, or a history of stroke.⁴
• AHI (apnea-hypopnea index) is the number of breathing pauses and shallow-breathing episodes per hour of sleep. Commonly used categories: 5 to under 15 mild, 15 to under 30 moderate, 30 or more severe.⁸

Treatment

• CPAP (continuous positive airway pressure): a quiet machine that keeps the airway open with gentle air pressure through a mask. It is the main standard treatment, and follow-up to fix mask or comfort problems helps people keep using it.⁹
• Oral appliance: a custom dental device that moves the lower jaw forward, an option for people who cannot use CPAP or prefer another approach.¹⁰
• Weight loss: in a long-term study, a 10% weight loss was associated with about a 26% drop in AHI.¹¹ Guidelines recommend a structured diet, activity, and behavioral program for people with OSA who are overweight.¹²
• Tirzepatide (Zepbound): on December 20, 2024, the FDA approved Zepbound for moderate-to-severe OSA in adults with obesity, used with a reduced-calorie diet and more physical activity.¹³ In the trials behind that approval, people on tirzepatide had about 20 to 24 fewer breathing events per hour than people on placebo after one year.¹⁴ The FDA notes the improvement is likely related to weight loss.¹³
• Other options, such as positional therapy or surgery, are chosen with a sleep specialist.

The association with NAION

• Pooled studies found NAION about 3 times as likely in people with sleep apnea.¹ An earlier, smaller pooled analysis of five studies estimated about 6 times the odds.²
• A Korean national study found an adjusted risk about 3.8 times higher in people with newly diagnosed sleep apnea than in similar people without it.³
• In a French study of 89 people who had already had NAION and had severe OSA, not using prescribed CPAP was associated with about 5.5 times the risk of NAION in the second eye.¹⁵ This does not prove CPAP prevents NAION.

Proposed reasons (not proven): repeated drops in oxygen at night, surges and swings in blood pressure, and strain on the optic nerve’s ability to regulate its own blood flow, all happening during the hours when NAION is thought to start. Sleep apnea is also associated with blood pressure that does not dip normally at night.¹⁶

GLP-1 medicines and sleep apnea

Weight loss on a GLP-1–based medicine may improve sleep apnea, and tirzepatide is FDA-approved for moderate-to-severe OSA in adults with obesity.¹³ The same medicine class also carries a labeled potential increased risk of NAION.¹⁷ If you have sleep apnea and take a GLP-1 medicine, keep using CPAP or your oral appliance unless your sleep doctor tells you otherwise, and ask whether a repeat sleep test makes sense after major weight loss.

Practical steps

• If you snore or are tired during the day, ask about a sleep test.
• If you have CPAP, use it every night.
• Keep regular visits with your usual doctor and sleep doctor, including blood pressure checks. Never stop or change a medicine without talking to the clinician who prescribes it.

For clinicians

Screening and diagnosis

• STOP-Bang (8 items, 0–8): score ≥3 had 93% sensitivity for AHI >15 and 100% for AHI >30 in the developers’ data; 0–2 low risk, 5–8 high risk, 3–4 intermediate (STOP-Bang ≥2 plus BMI >35 kg/m² reclassifies to high risk).⁶ Originally validated in surgical patients.⁵
• Epworth (ESS): 8 items, total 0–24; correlates with sleep latency and, in OSA, with RDI and nadir SaO₂.⁷
• AASM: do not diagnose OSA with questionnaires or prediction tools alone; PSG or a technically adequate HSAT for uncomplicated adults with increased risk of moderate-to-severe OSA; PSG for significant cardiorespiratory disease, neuromuscular weakness, hypoventilation, chronic opioids, stroke, or severe insomnia, and after a negative or inadequate HSAT.⁴
• AHI severity: 5–<15 mild, 15–<30 moderate, ≥30 severe.⁸

Management

• PAP: base on objective testing; ensure early follow-up with objective adherence and efficacy data.⁹
• Oral appliance therapy for patients intolerant of CPAP or preferring an alternative, using a custom, titratable device with dental and sleep follow-up.¹⁰
• Weight management: ATS strong recommendation for comprehensive lifestyle intervention; pharmacotherapy and bariatric surgery for selected patients.¹² A 10% weight loss predicted a 26% AHI reduction (Wisconsin cohort).¹¹
• Tirzepatide: FDA approved for moderate-to-severe OSA in adults with obesity (Dec 20, 2024).¹³ SURMOUNT-OSA (52 weeks): treatment difference in AHI −20.0 events/h without PAP and −23.8 events/h with PAP.¹⁴

NAION relevance

• Sleep apnea RR 3.28 (95% CI 2.08–5.17) in a 49-study meta-analysis;¹ OR 6.18 (2.00–19.11) in a 2016 meta-analysis of five studies, with an association retained in studies matched for systemic risk factors.²
• Korean national cohort: 919 OSA vs 9,190 controls, aHR 3.80.³ Aptel 2015: CPAP non-adherence and fellow-eye NAION, HR 5.54.¹⁵
• Proposed mechanisms: nocturnal hypoxemia, BP surges and variability, and impaired ONH autoregulation. OSA is associated with non-dipping and nocturnal hypertension.¹⁶
• OSA is also a confounder in observational GLP-1 RA–NAION studies (confounding by indication).

In practice

• Ask about OSA symptoms in every NAION patient and every patient with a disc at risk; refer for testing when indicated.
• In patients on GLP-1–based therapy, weight loss may reduce OSA severity; repeat testing and PAP adjustment are decisions for the sleep clinician.

How to reach us

Same-day evaluation: providers can call the office at 570-453-2020 (fax 570-453-1020), or refer a patient or ask a question by email. Patients can schedule an exam online.

For privacy, please don’t include patient names or other identifying details in email. Our team will call to schedule and gather details securely.

General contact and referrals: Hazleton Eye Specialists, phone 570-453-2020, fax 570-453-1020. See Referral information for what to send.

References

1. Liu B, et al. Risk factors for non-arteritic anterior ischemic optic neuropathy: a large scale meta-analysis. Front Med (Lausanne). 2021;8:618353. https://pubmed.ncbi.nlm.nih.gov/34671609/
2. Wu Y, et al. The association between obstructive sleep apnea and nonarteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis. Curr Eye Res. 2016;41(7):987-992. https://pubmed.ncbi.nlm.nih.gov/26443989/
3. Obstructive sleep apnoea and increased risk of non-arteritic anterior ischaemic optic neuropathy (Korean national cohort). Br J Ophthalmol. 2019;103(8):1123. https://bjo.bmj.com/content/103/8/1123
4. Kapur VK, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479-504. https://pubmed.ncbi.nlm.nih.gov/28162150/
5. Chung F, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. https://pubmed.ncbi.nlm.nih.gov/18431116/
6. Chung F, et al. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631-638. https://pubmed.ncbi.nlm.nih.gov/26378880/
7. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545. https://pubmed.ncbi.nlm.nih.gov/1798888/
8. American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep. 1999;22(5):667-689. https://pubmed.ncbi.nlm.nih.gov/10450601/
9. Patil SP, et al. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335-343. https://pubmed.ncbi.nlm.nih.gov/30736887/
10. Ramar K, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827. https://pubmed.ncbi.nlm.nih.gov/26094920/
11. Peppard PE, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015-3021. https://pubmed.ncbi.nlm.nih.gov/11122588/
12. Hudgel DW, et al. The role of weight management in the treatment of adult obstructive sleep apnea. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2018;198(6):e70-e87. https://pubmed.ncbi.nlm.nih.gov/30215551/
13. U.S. Food and Drug Administration. FDA approves medication for obstructive sleep apnea (press announcement, Dec 20, 2024). https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea
14. Malhotra A, et al. Tirzepatide for the treatment of obstructive sleep apnea and obesity. N Engl J Med. 2024;391(13):1193-1205. https://pubmed.ncbi.nlm.nih.gov/38912654/
15. Aptel F, et al. Association of nonarteritic ischemic optic neuropathy with obstructive sleep apnea syndrome: consequences for obstructive sleep apnea screening and treatment. JAMA Ophthalmol. 2015. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2276934
16. Parati G, et al. Nocturnal blood pressure: pathophysiology, measurement and clinical implications. Position paper of the European Society of Hypertension. J Hypertens. 2025;43(8):1296-1318. https://pubmed.ncbi.nlm.nih.gov/40509714/
17. U.S. Food and Drug Administration. Drug Safety Communication on GLP-1 RA labeling and NAION, Nov 9, 2026. https://www.fda.gov/drugs/drug-safety-communications/fda-requires-safety-labeling-changes-glucagon-peptide-1-receptor-agonists-glp-1-ras-due-potential

Medical disclaimer. This page is for general education. The patient section is not medical advice, and the clinician section is not a clinical practice guideline; neither replaces an examination, clinical judgment, or specialty consultation. If you have sudden vision loss, seek same-day care from an eye doctor or an emergency department. Information is current as of the “last reviewed” date.