The eyes again

I have been having trouble with swollen eyes in the morning. The actual eyeball. I guess it's called chemosis, where the white of the eye is puffed out. I tried a couple of things. Thursday night I wore my Airfit N10 for her and eyeeco goggles over my eyes. The goggles formed a good seal, in fact the next morning I had obvious red half-circles under my eyes from where the goggles pressed in. Thus it would have been difficult for mask leakage to get under the goggles. And still the eyes were swollen. Last night I tried a new nasal mask, the Pico, and I was pleased with the smaller nose cushion and its seal and also how the exhaust points away from the face. The leak graph looks pretty good this morning and what I do see I think came out my mouth. And still my eyes were swollen. My guess at this point is that I have pretty much proven that the air that is irritating my eyes is coming up through the tear ducts in my nose. I am using a thick ointment in my eyes at night and a gel in the morning. By around noon they look normal, but I am concerned about the long-term effects of irritating my eyes to this extent every night. I wondered if the only option I have left in terms of masks is that one that covers the entire face.

BTW I know there's a mask that is mouth-only, right? That would be super tough for me especially since I had surgery on my nose so that I could breathe clearly through it at night (septoplasty and turbinectomy). Good lord but this is frustrating.

Did your surgery work, and is it healed? Then you should be able to use the oral mask, right?

Yes, there is a mouth only mask but your nose has to be useless (or physically blocked with clips) and I would have such a problem with that. I am such a nose breather that switching to mouth only would be a huge change and a change that I don't know that I could make.

Now those masks like the Fit Life...I did briefly try the Fit Life just to see what it felt like in terms of pressure on the eye and it really was a non issue and that kind of surprised me. Not nearly as weird of a feeling as I thought it would be. I had huge problems getting it to seal though (and I was using the small size which should have worked). I got it to seal for about 10 seconds and after that I couldn't ever get it back. There's a lot of real estate involved compared to what I have been used to using.

You might put out a request here on the forum for a gently used FitLife just to try for a short while to see if it would work for you with your needs so that you don't have to spend a lot of money. Heck, the return insurance isn't cheap for that mask at $32 but if you want to go that route at least you won't blow $119 should it not work.
I gave the one I had away or you could have it to try.

I would report the air-in-eyes problem to both your sleep doctor and your eye doctor. In reporting the problem, you should indicate why you are sure the problem is air leaking into your eyes through the tear ducts rather than mask leaks or intentional venting from the mask hitting your eyes. Air getting into the eyes through the tear ducts is not a very common problem, but it's not unheard of either.

When I was just starting out, I had some problems with air getting into my eyes via the tear ducts. It's a very weird and uncomfortable feeling. I had been titrated at 9cm and between my reports of "air in the eyes coming through the tear ducts" and "rock hard and basketball swelling in the abdomen", the PA switched me to an APAP with a lower pressure range of 4-8cm. As long as my pressures stay at or below 8cm, I seem to be fine. So one thing that might help is a slight reduction in air pressure.

I've also read that there are medical devices that can be used to block the tear ducts if necessary. That's why I'd suggest talking to both the eye doctor and the sleep doctor. You may need to get them working together to solve your problem.

My surgery was in 1998. I would not have had that surgery if I in any way could tolerate mouth breathing. It was a nasty surgery with none of the nice laser techniques they have today but I was desperate to be able to breathe through my nose at night. Pugsy I see that you get it when I say I don't think I could do it. I think I would need a size small Fit Life too. $32 return insurance?? Do you think a homemade mask liner could have helped with the seal or were the leaks just too huge?

Do you set your machine to FFM for the Fit Life? It seems like it would need its own category, as big as it is.

Robysue, I have been to the ophthalmologist, one of the best in my city, and he shrugged and said to use ointment. He went and talked to a dry eye expert in the building and the guy said the same thing. The ophthalmologist indicated that he thought it was tear duct leaking. I don't actually feel air coming through the tear ducts. You did? This is why I am not 100% certain. Did you get the swelling of the whites of your eyes? I am also trying to figure out if I could be allergic to something, but my skin and eyelids are fine. BTW I have had punctal plugs in the past and the ophthalmologist said the pressure would just blow them out. As I recall there is a surgery where the puncta can be surgically closed, but I'm wary.

Robysue, I am thinking about what you said about pressure. I think I started to have trouble with my eyes when I went from a straight cpap of 8 to apap 5-9 with the machine often going to 9, and now my apap is 7-10 with it often hanging out at 10. I am not at a point where I mess with the settings without consulting my sleep nurse, but it's Saturday and I think tonight I'm going to set it back to cpap 8 and see how my eyes are. Thanks for that idea! I can imagine a compromise between "ideal" pressure and what my eyes can tolerate.

One last thing, Robysue, if you were titrated at 9, is your apnea adequately controlled with 4-8 apap? Do you think the 9 was not accurate for you?

I am thinking that a mask liner for the FitLife would simply have to be too large to be practical.

Yes, return insurance for the FitLife from cpap.com is around $32. How the return insurance works is that you purchase the return insurance (sometimes it is free but not in this situation) and you have 30 days (from the time it leaves cpap.com) to get it back to cpap.com should it not work out. Cpap.com will even provide a printable shipping label. So if you end up hating the mask then all you are out is the cost of the return insurance.
That's the way cpap.com does all the return insurance...kinda nice when the masks come with free return insurance.
This works well for users in the US but not so well for outside the US because customs always eats up an unknown amount of time both in sending out and returning to cpap.com.

Though I think if it were me I would do what you are thinking about doing...just try reducing the pressure a little and see if less pressure resolves the issue and not compromise therapy.
Sometimes we can make compromises that don't seriously impact therapy effectiveness.

Pugsy, yeah, I just returned an FX Nano for her to cpap.com two days ago. I won't be rushing to get (or find) a Fit Life until I explore the pressure options. I'm excited that there's another avenue to explore that would allow me to wear a more comfortable mask.

AMK wrote:I don't actually feel air coming through the tear ducts. You did? This is why I am not 100% certain. Did you get the swelling of the whites of your eyes? I am also trying to figure out if I could be allergic to something, but my skin and eyelids are fine. BTW I have had punctal plugs in the past and the ophthalmologist said the pressure would just blow them out.

Yes, I could feel the air coming through my tear ducts. But I'm very, very sensitive to physical stimuli of all sorts. I could confirm that the air was coming through the tear ducts by pressing my finger on the inside corner of my eye and that would stop the sensation and if I relaxed the pressure my finger was putting on my eye, the air-in-eye sensation would return. The finger was in the same position regardless of whether I put pressure on the inside corner of my eye or not---so I new that where the finger was located was NOT what was blocking the air flow.

My eyes certainly felt "puffy", but I don't recall if there was visible swelling or not.

AMK wrote:One last thing, Robysue, if you were titrated at 9, is your apnea adequately controlled with 4-8 apap? Do you think the 9 was not accurate for you?

On my first titration study they had me at 7cm for a very long time. I had a rather lengthy "WAKE" stretch sometime after 5:00 AM and I fell back asleep about 10-15 minutes before the sleep test was to end at 6:00AM and I immediately had two hypopneas. Because of the test was scheduled to end within 10-15 minutes, the tech jumped the pressure from 7cm to 9cm without testing me at 8cm. I had no more events in the remaining 10-15 minutes of the sleep test, and that's what my original script was based on.

There's strong objective evidence that I was over titrated at 9cm on that first titration test: Because of lengthy and extreme problems with adjusting to PAP therapy and on-going problems with insomnia, I've since had 3 additional titration studies done with bi-level. The recommended pressures for those studies were:

First BiPAP titration: IPAP/EPAP = 8/6
Second BiPAP titration: IPAP/EPAP = 7/4
Third BiPAP titration: IPAP/EPAP = 6/4

Long term home data indicates that fixed BiPAP pressures of 7/4 and 6/4 does NOT control my snoring (but the AHI is still consistently below the 5.0 line). Fixed BiPAP pressures of 8/6 does control my snoring and my OSA, but it leads to real problems with aerophagia. BiPAP Auto with min EPAP = 4 and max IPAP = 8 allows the machine to do a good job in controlling the snoring and the AHI without causing too many problems with aerophagia. My nightly median IPAP/EPAP pressures are typically median IPAP between 7 and 8 and median EPAP between 4 and 5. My 90% IPAP/EPAP pressures are usually 8/5 or 8/4.

Robysue, I am thinking about what you said about pressure. I think I started to have trouble with my eyes when I went from a straight cpap of 8 to apap 5-9 with the machine often going to 9, and now my apap is 7-10 with it often hanging out at 10. I am not at a point where I mess with the settings without consulting my sleep nurse, but it's Saturday and I think tonight I'm going to set it back to cpap 8 and see how my eyes are. Thanks for that idea! I can imagine a compromise between "ideal" pressure and what my eyes can tolerate.

For me, the difference between 8cm and 9cm was critical when it came to the eyes.

Out of curiosity: Why were you switched from CPAP = 8 to APAP = 5-9 to APAP = 7-10? Was CPAP=8 not adequately controlling the OSA? And have you looked at the data closely enough to see what is triggering the pressure to go to the 9-10 range?

I ask because when I've experimented with increasing my max IPAP setting from 8cm to 9, 10, or 11cm (in an effort to reduce my flow limitation index), I have found that the increased pressure is driven by flow limitations and snoring. And that makes the 90% pressure levels go up higher than my usual setting of 8/6. But the additional pressure doesn't really control my already acceptable numbers any better AND I feel substantially worse because of increased aerophagia and once the IPAP is above 9 or 10cm or so, the "air through the tear ducts" sensation comes back.

BTW I have had punctal plugs in the past and the ophthalmologist said the pressure would just blow them out. As I recall there is a surgery where the puncta can be surgically closed, but I'm wary.

Does the ophthalmologist know that you are NOT using exceptionally high pressures? In other words, if inserting the plugs is not particularly invasive, then it may be worth a try anyway. You might also ask the sleep doc if he has any patients who have had punctual plugs put in and are doing ok with them.

You need to see an ophthalmologist (Not an optometrist) and one who is familiar with xpap therapy.
Do not try to treat this yourself. Eyes are very fragile.

SEE YOUR EYE DOCTOR!
Eye damage is too often irreversible--you do NOT get a do-over!

chunkyfrog wrote:SEE YOUR EYE DOCTOR!
Eye damage is too often irreversible--you do NOT get a do-over!

and

BlackSpinner wrote:You need to see an ophthalmologist (Not an optometrist) and one who is familiar with xpap therapy.
Do not try to treat this yourself. Eyes are very fragile.

The problem is that AMK has seen an opthalmologist who just doesn't get it:

AMK wrote:Robysue, I have been to the ophthalmologist, one of the best in my city, and he shrugged and said to use ointment. He went and talked to a dry eye expert in the building and the guy said the same thing. The ophthalmologist indicated that he thought it was tear duct leaking.
...
BTW I have had punctal plugs in the past and the ophthalmologist said the pressure would just blow them out. As I recall there is a surgery where the puncta can be surgically closed, but I'm wary.

So, yes, AMK needs to see an opthalmologist who understands that something other than dry eye ointment needs to be looked into. That's why I've suggested that AMK needs to work with both the sleep doc AND an ophtalmologist: Perhaps the sleep doc could recommend an ophtalmologist who is familiar with how CPAP air can get into the tear ducts and what kinds of measures can be taken to help minimize air leaking into the eyes through the tear ducts.

And if (as in my case) a small reduction in pressure results in both (no tear duct leakage) and (sufficient control of the OSA), then reducing the pressure may be the easiest way to fix the problem.

Yes, the morning I got up the week before last and the whites of my eyes were not only swollen but cherry red, I called and the ophthalmologist fit me in that day. I will be letting the sleep nurse (one must go through the gatekeepers) know the situation. I had thought there was a chance the N10 was just blowing into my eyes since it's a bit of a leaky mask for me, so my careful experimentation of the last few days has pretty much ruled that out. Thank goodness I "just" get swollen whites now and they aren't that wild red anymore, but still I know better than to let this go on indefinitely.

Robysue, during my titration study I spent very little time in REM which is where I stop breathing the most, so I've gotten the impression that the choice of 8 as my pressure was a bit of a shot in the dark. When I looked at my data in Sleepyhead, I saw a lot of flow limitations even though my AHI looked good. I asked if I could try apap and the sleep nurse chose 5-9. Since my pressure some nights went to 9 and stayed there, I asked about 7-10. But all this raising the pressure isn't making my flow limitation graph look any calmer. I'm not sure anymore that the goal of a good flow limitation graph is a good goal for me. You can see last night that 7-10 isn't dampening the flow limitations and in fact my AHI is worsening (and what is up with that hour o' doom around 2-3AM).