Nationwide Study Links Insomnia and Sleep Apnea to Glaucoma Incidence

A new analysis combining data from a population-based cohort and a nationwide claims database in Japan reveals that both short sleep duration and diagnosed sleep disorders—insomnia and sleep apnea—are significantly associated with increased glaucoma risk. The findings suggest potential neurodegenerative mechanisms linking poor sleep to retinal nerve fiber layer thinning and underscore the importance of considering sleep health in glaucoma management. Photo: Justin Cole, OD, and Jarett Mazzarella, OD. Click image to enlarge. Sleep disturbances such as insomnia and sleep apnea contribute to various physical and mental health outcomes, increasing risk of certain diseases, particularly glaucoma. Insomnia can affect the regulation of intraocular pressure and blood flow, while sleep apnea induces inflammatory responses, all of which are known contributors to the disease. Large-scale, nationwide investigations on relationships between sleep quality on retinal nerve fiber layer (RNFL) thinning are lacking, which prompted a group of researchers to combine two databases in Japan in hopes of revealing a significant association. These results were recently published in American Journal of Ophthalmology.The two primary data sources used in this study were the Nagahama Prospective Cohort for Comprehensive Bioscience (the Nagahama study), which included 5,958 adults aged 40 to 80, all of whom had no serious diseases or physical impairments; and the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), a nationwide claims database that covers almost all insured citizens in Japan, amounting to 985,136 patients (36.4% male) with insomnia and 72,075 (81% male) with sleep apnea, all of whom were aged ≥40 years. The study authors used a two-pronged approach, first conducting a cross-sectional analysis in the Nagahama study to find associations between sleep duration and RNFL thickness. Then they employed the NDB to examine the connection between diagnosed insomnia and sleep apnea with glaucoma incidence in the population. Researchers performed a longitudinal analysis, estimating adjusted hazard ratios (aHR) for incident glaucoma.The regional cohort results found the following: RNFL thickness peaked at six to seven hours of actual sleep and declined with shorter duration. Sleeping less than six hours remained independently associated with thinner RNFL after adjusting for age, sex, IOP and systemic factors. Notably, sleep efficiency was not significantly correlated with RNFL thickness, and IOP showed significant differences across sleep duration categories, being highest in the seven- to eight-hour sleep duration group. In the nationwide cohort, glaucoma risk was higher in patients with insomnia (aHR 1.30) and apnea (aHR 1.43) compared with controls. During the follow-up period, among the 985,136 patients sampled for insomnia and 72,075 patients sampled for sleep apnea, 18,954 and 1,276 were newly diagnosed with glaucoma, respectively. The Kaplan-Meier analysis revealed that patients with insomnia and apnea exhibited an increased risk of developing glaucoma.In their paper, the authors discuss potential mechanisms underlying these associations. For insomnia, chronically reduced ocular blood flow is a known risk factor for both onset and progression of glaucoma. Furthermore, impaired sleep may lead to dysfunction of the glymphatic system, which facilitates waste clearance from the brain and potentially the retina, promoting the accumulation of amyloid-beta (Aβ). “As Aβ pathology is implicated in the pathogenesis of glaucoma, insomnia-related glymphatic dysfunction may lead to waste accumulation at the retinal level, ultimately causing retinal ganglion cell degeneration,” the authors wrote.For sleep apnea, the study highlights the role of intermittent hypoxia and oxidative stress, which trigger inflammatory responses that contribute to glaucoma development. “This inflammation is considered to play a significant role in glaucoma development,” the authors continued in their discussion. “As a result, patients with SAS may experience not only the Aβ-related risk associated with insomnia-induced glymphatic dysfunction but also the compounded effects of hypoxia, oxidative stress and systemic inflammation. Collectively, these factors may intensify the likelihood of glaucoma development and progression.”Despite its strengths, including objective sleep measurements and large-scale population data, the study acknowledges several limitations. The cross-sectional design of the Nagahama study prevents definitive conclusions about causality, and its enrollment criteria of apparently healthy, community-dwelling adults may limit generalizability to populations with significant illness or functional impairment. The NDB analysis relied on diagnostic and prescription codes, which could affect the precision of disease classification, and lacked detailed information on visual acuity and fields.Nevertheless, the authors say these findings across both cohorts suggest a significant association between objective sleep insufficiency and clinically diagnosed sleep disorders with retinal neurodegeneration and a higher risk of developing glaucoma. “These findings suggest that sleep‑related factors could be taken into account when managing glaucoma,” they concluded. “Further studies are required to confirm these associations and explore how interventions for sleep disorders might modify glaucoma progression.”Click here for the journal source. Akada, Masahiro et al. Sleep disturbance as a risk factor for retinal neurodegeneration and subsequent glaucoma. Am J Ophthalmol. August 15, 2025. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.