Optic neuropathy in uremia

Multimodal ocular evaluation in hemodialysis patients

PURPOSE

To evaluate choroidal thickness, intraocular pressure (IOP), axial length, central corneal thickness (CCT), lens thickness, anterior chamber depth, and ocular pulse amplitude (OPA) in hemodialysis patients.

MATERIALS AND METHODS

The patients with end-stage renal disease and undergoing hemodialysis were included in the study. Immediately before and 1 hour after hemodialysis, all patients underwent measurement of choroidal thickness with spectral domain optical coherence tomography (SD-OC, Cirrus HD-OCT; Carl Zeiss Meditec Inc., Dublin, CA), IOP and OPA with Pascal dynamic contour tonometry (Ziemer Ophthalmic Systems AG, Port, Switzerland), and anterior chamber depth, lens thickness, and axial length with optical biometry (LenStar LS900; Haag-Streit AG, Koeniz, Switzerland). Data from the patients' right eyes were included in the statistical analysis.

RESULTS

The patient group included 8 (36.4%) males and 14 (63.6%) females with a mean age of 56, 14 ± 9, 96 (40-70) years. The mean subfoveal choroidal thickness before and after hemodialysis was 255.21 ± 6.15 (245-263) µm and 234.95 ± 7.89 (220-247) µm, respectively (p < 0.001). Mean choroidal thickness at 1500 µm and 3000 µm nasal and temporal of the fovea also decreased significantly after hemodialysis (p < 0.001). Mean OPA values before and after hemodialysis were 2.14 ± 1.07 (0.6-4) mmHg and 1.6 ± 0.86 (0.5-3.2) mmHg, respectively (p < 0.001). There was a statistically significant correlation between OPA and choroidal thickness measurements (p < 0.001, R = 0.923). IOP increased from 15.11 ± 2.58 (11-20) to 15.99 ± 2.21 (13-20) mmHg, but the change did not reach statistical significance (p = 0.05). There was no statistically significant change in mean axial length, anterior chamber depth, lens thickness, or CCT after hemodialysis (p > 0.05 for all).

CONCLUSION

Although choroidal thickness and OPA may be decreased immediately after hemodialysis, there may be no significant changes in IOP or avascular ocular structures such as the lens and cornea.

Sequential nonarteritic anterior ischemic optic neuropathy in patient on chronic hemodialysis

Nonarteritic anterior ischemic optic neuropathy (NAION) is a well acknowledged rare complication of chronic hemodialysis in patients with end-stage renal disease (ESRD). We present a unique case of a patient on chronic hemodialysis who presented with an NAION in the right eye, then 3 months later developed an NAION in the left eye followed in 1 month by second NAION episode in the left eye. Every episode of NAION was accompanied by intradialytic hypotension (drop in systolic blood pressure of over 20 mmHg) where visual loss was noticed at the end of the dialysis session. Clinicians should be aware of association between NAION and hemodialysis and that patients with dialysis-induced hypotension are at particularly increased risk of having NAION. Patients who had dialysis-associated NAION should be closely monitored to prevent occurrence of intra-dialytic hypotension as they are at the highest risk of sequential NAION and thus severe visual loss.

Effect of hemodialysis (HD) on intraocular pressure, ocular surface, and macular change in patients with chronic renal failure. Effect of hemodialysis on the ophthalmologic findings

BACKGROUND

The main objective of hemodialysis (HD) is to correct the excessive accumulation and abnormal distribution of body fluid. Therefore, changes in the systemic hemodynamic parameters and in the ocular fluid volume and composition can occur during a single HD session. The aim of this study is to evaluate the short-term changes in the ophthalmologic findings after HD.

METHODS

Thirty eyes of 30 patients with chronic renal failure (CRF) undergoing HD were analyzed. The subjects were categorized into two groups according to the cause of CRF. Detailed ophthalmologic examinations were performed immediately before and after HD. The relationships between the systemic hemodynamic changes and the ophthalmologic changes during a single HD session were evaluated.

RESULTS

The results show that a body fluid correction after HD involves a change in the plasma colloid osmotic pressure. The mean intraocular pressure (IOP) decreased after HD with a mean decrease of 2.4 ± 2.1 mmHg and the central corneal thickness decreased with a mean change of 6.9 ± 5.4 μm. After HD, the ocular surface changed significantly; the tear break-up time (TBUT) and basal tear secretion (Schirmer's test) decreased, whereas the keratoepitheliopathy score increased. The macular thickness measured by spectral domain optical coherence tomography (SD-OCT) decreased after HD. The mean decrease in the central subfield thickness was 7.4 ± 9.9 μm. The ocular surface changes after HD affected the visual acuity and examination quality. A significant correlation was found between the changes in the systemic hemodynamic parameters and those in the ophthalmologic findings, except for the retinal thickness.

CONCLUSIONS

The changes in the ophthalmologic findings after HD were consistent and significant in all CRF subjects. These changes correlated with the increase in plasma colloid osmotic pressure. HD can correct the volume and composition of ocular fluid. Therefore, it can affect the ophthalmologic findings in a short period of time. In addition, for good examination quality, it is recommended that an ophthalmologic examination in CRF patients be performed on a non-dialysis day or prior to HD on a dialysis day. Furthermore, for accurate comparison of examination results, the time interval from an HD session to an ophthalmologic examination must be considered.

Uremic optic neuropathy with severe epiretinal membrane formation

PURPOSE

The purpose of this study was to describe a patient with uremic optic neuropathy and concomitant epiretinal membrane formation.

METHODS

The patient was investigated by standard ophthalmoscopy, blood samples, and by radiography.

PATIENT

A 24-year-old woman with renal failure.

RESULTS

Severe optic nerve head edema and massive epiretinal fibrosis with central retinal tractional detachment were found in both eyes. Surgical intervention resulted in attachment of the right retina, whereas the condition resulted in chronic detachment of the left retina despite repeated treatment.

CONCLUSION

To our knowledge, the combination of uremic optic neuropathy and massive epiretinal membrane formation has not been described previously. Strategies for managing this severe visually threatening condition are discussed.

Bilateral anterior ischemic optic neuropathy in patients on dialysis: A report of two cases

Patients under chronic dialysis treatment suffer from atherosclerotic disease and anemia more frequently than the normal population. This, together with the frequent hypotension, put these patients at increased risk for anterior ischemic optic neuropathy (AION), which may be bilateral and blinding. We present two cases of patients under chronic dialysis who developed bilateral AION after hypotensive events. Bilateral involvement is not unusual in renal replacement patients who suffer from AION. Efforts should be focused on prevention of this complication by improving anemia and blood pressure control because once established, treatment will probably be ineffective.

Calciphylaxis and bilateral optic neuropathy

A 51-year-old woman on hemodialysis for chronic renal failure complained of visual loss in her right eye. Right optic disc edema was observed on fundus examination. An arteritic optic neuropathy was suspected. However, a first biopsy did not reveal any inflammatory cells. Two months later, the patient experienced sudden visual loss in her left eye and presented with necrotic cutaneous lesions at the distal phalanges of several fingers of the right hand. Necrotic lesions also appeared on the inner aspect of the thighs. Biopsy of the cutaneous lesions revealed calcification in the wall of a small artery. A new biopsy of the temporal artery showed large calcium deposits in the artery's tunica media. The diagnosis of optic neuropathy secondary to calciphylaxis was made. A temporal artery biopsy should be repeated if the first one is inconclusive. An early diagnosis leading to appropriate treatment may help to prevent an irreversible loss of vision in these patients.

Ischemic optic neuropathy in dialyzed patients: A previously unrecognized manifestation of calcific uremic arteriolopathy

Two patients with end-stage renal disease and on long-term hemodialysis presented with hypotension and an acute unilateral loss of vision. A diagnosis of anterior ischemic optic neuropathy (AION) was made quickly, but despite high-dose steroid therapy, significant vision was not recovered. Temporal artery biopsy results showed extensive medial calcification. The possibility that hypotension, when coupled with calcific uremic arteriolopathy in arteries supplying the optic nerve head, will lead to AION in dialyzed patients is discussed. A short review of AION in the dialysis population is given.

Effect of haemodialysis on retinal circulation in patients with end stage renal disease

AIMS

To investigate the effect of haemodialysis on retinal circulation in patients with end stage renal disease (ESRD).

METHOD

Seventeen consecutive patients with ESRD were recruited into the study. The authors simultaneously measured changes in vessel diameter and blood velocity and calculated the retinal blood flow (RBF) in the retinal veins in patients with ESRD before and after haemodialysis using a laser Doppler velocimetry system. In addition, the relations between the changes in systemic and retinal circulatory parameters were examined.

RESULTS

There was a group averaged increase in vessel diameter (p = 0.003) after haemodialysis. However, the blood velocity and RBF values obtained after haemodialysis were not significantly different from those before haemodialysis (p = 0.66 and p = 0.63, respectively). The changes in vessel diameter were negatively (r = -0.549, p = 0.02) correlated with the change in MABP, but the changes in blood velocity and RBF were positively correlated with the change in MABP (r = 0.683, p<0.002 and r = 0.589, p<0.01, respectively). The change in RBF was also inversely correlated with the increase in haematocrit (r = -0.693, p<0.002) and the amount of fluid removed (r = -0.597, p<0.01).

CONCLUSION

The results indicate that haemodialysis and the associated changes in systemic circulatory parameters may affect the retinal circulation in patients with ESRD.

Sudden blindness caused by anterior ischemic optic neuropathy in 5 children on continuous peritoneal dialysis1 1Published partially (case 3) in abstract form in Arch Ped 7:437, 2000, and in Pediatr Nephrol 16:C4, 2001

The authors report the occurrence of sudden blindness in 5 children (mean age, 32 months; range, 11 to 60) during continuous peritoneal dialysis regimen. All children presented with loss of light perception, visual fixation and ocular pursuit, and bilateral mydriasis unreactive to bright light. Fundoscopic examination found signs of anterior ischemic optic neuropathy with disc swelling, edema, and hemorrhages. Whereas 1 patient was dehydrated, the 4 other patients appeared well and not dehydrated. Nevertheless, blood pressure was below the normal range in all of them. Therefore, hypovolemia is highly suspected to have been the cause of ischemic optic neuropathy in all cases. Treatment consisted of steroids (4 patients), anticoagulation or antiagregation drugs (3 patients), plasma or macromolecules infusions (2 patients), vasodilatators (2 patients), and transient dialysis interruption (1 patient). One child with hepatic cirrhosis died 4 days later of acute liver insufficiency owing to ischemic hepatic necrosis. The other children had only partial improvement of vision during the following months. Because the prognosis of ischemic optic neuropathy is very poor, diagnosis and treatment of chronic hypovolemia in children on continuous peritoneal dialysis is essential to prevent such a devastating complication.

The effect of hemodialysis on visual field test in patients with chronic renal failure

PURPOSE

To investigate the visual field with FASTPAC 30-2 program before and after hemodialysis in patients with end stage renal disease.

MATERIALS AND METHODS

Twenty eyes of 20 patients on regular hemodialysis were included in the study group. Twenty eyes of 20 healthy patients were chosen as control group. Intraocular pressures (IOP) were measured one hour before and one hour after the same hemodialysis session, and visual field was tested at the same times.

RESULTS

When IOP was compared before and after hemodialysis, no statistically significant difference was found (p > 0.05), however Mean Deviation (MD) (p = 0.008) improved after hemodialysis. When we compared first global indices of the control group with pre-hemodialysis global indices, we noted significant difference in MD (p = 0.009).

CONCLUSION

Visual field testing should be done after hemodialysis in patients who are on regular hemodialysis program.

Retinal light sensitivity in haemodialysis patients

PURPOSE

The aim of the present study was to compare retinal light sensitivity between normal healthy subjects and chronic renal failure patients treated with maintenance haemodialysis (HD), as well as to determine whether there is a correlation between visual field loss and the age of HD patients, duration of HD treatment and hypertensive retinopathy in HD patients.

METHODS

A total of 50 eyes of 25 HD patients (16 male, nine female) and 30 eyes of 15 controls underwent visual field testing on the C 30-2 program of the Humphrey field analyser.

RESULTS

Significant reduction in retinal light sensitivity with mean deviation (MD) P values less than 5% was found in 36% (18 eyes), pattern standard deviation (PSD) P values less than 5% in 16 eyes (32%) and corrected pattern standard deviation (CPSD) P values less than 5% in 16 eyes (32%) of HD patients. In control group, all MD, PSD, and CPSD P values were within normal limits. No correlation between reduction of retinal light sensitivity and age or duration of dialysis treatment was observed in HD patients. The reduction of retinal light sensitivity was significantly greater in HD patients with hypertensive retinopathy.

CONCLUSION

In 36% of eyes from our HD patients without ophthalmoscopically evident arteriolar occlusion on fundus examination, a significant reduction in retinal light sensitivity was observed. The reduction was significantly greater in HD patients with hypertensive retinopathy.

Anterior ischemic optic neuropathy in children: case reports and review of the literature

Anterior ischemic optic neuropathy, infarction of the optic nerve head owing to inadequate perfusion through the posterior ciliary arteries, is a common cause of visual loss in adults but is rarely reported in children, in part because the diagnosis is overlooked. We report two cases of young children undergoing chronic peritoneal dialysis, who suffered bilateral visual loss from anterior ischemic optic neuropathy. Predisposing local anatomic and multiple systemic factors included a small optic nerve head with little cupping, possible intraocular hypertension, and systemic hypotension, hypovolemia, and anemia. The literature on anterior ischemic optic neuropathy is reviewed.

Optic neuropathy in uremia: an interdisciplinary emergency

Optic neuropathy in uremia is rare. Although the consequences of optic neuropathy-blindness or substantial loss of vision-are devastating, only a few cases have been reported by way of single case reports and case series studies. The reported patients are heterogeneous with regard to the cause of neuropathy. We report the case of a patient with uremic optic neuropathy and summarize the other cases reported in the literature so far. Based on the data available from these reports, we propose a classification system, which includes nonischemic neurotoxic uremic optic neuropathy; ischemic optic neuropathy, more specifically anterior ischemic optic neuropathy; and optic neuropathy as a result of drug side effects, benign intracranial hypertension, and optic neuritis. The immediate institution of dialysis and corticosteroid therapy and correction of anemia and relative hypotension can optimize the chances of visual recovery for these patients. Close collaboration among nephrologists, ophthalmologists, and neurologists is important in this interdisciplinary emergency.

Hypotensive ischemic optic neuropathy and peritoneal dialysis

PURPOSE

To report anterior ischemic optic neuropathy associated with systemic hypotension in a patient undergoing continuous ambulatory peritoneal dialysis.

METHODS

Case report. A 58-year-old man undergoing continuous ambulatory peritoneal dialysis developed painless blurred vision in both eyes and bilateral optic disk swelling with an altitudinal field defect in the left eye. Twenty-four-hour ambulatory blood pressure monitoring was requested in addition to other routine investigations.

RESULTS

Routine blood pressure measurement in the clinic was 130/86 mm Hg, but ambulatory blood pressure monitoring demonstrated pronounced early morning hypotension with individual readings as low as 91/41 mm Hg.

CONCLUSIONS

Renal dialysis can render patients hypotensive, and this may be associated with anterior ischemic optic neuropathy. The overnight drop in blood pressure may not be appreciated with routine blood pressure measurement. Therefore, 24-hour ambulatory blood pressure monitoring should be considered when investigating patients with suspected anterior ischemic optic neuropathy who are undergoing renal replacement.

Anterior ischemic optic neuropathy

AION is the most common acute optic neuropathy in patients over 50 and, although the diagnosis is often straightforward, our methods for managing the associated visual loss are inadequate. Analysis of the wealth of information gained from recent clinical studies may move us closer to an effective therapy.

Two brothers with bilateral optic neuropathy

A young man developed bilateral, consecutive, optic neuropathy. His brother had had a similar problem and recovered after one year. Mitochondrial DNA analysis showed that both had the 14484 mutation associated with Leber's hereditary optic neuropathy.

Salvage of vision after hypotension-induced ischemic optic neuropathy

No effective treatment has been established for nonarteritic anterior ischemic optic neuropathy. Although most cases occur spontaneously, acute hypotension plays a clear role in a subset of patients. We examined three patients with severe visual loss from ischemic optic neuropathy induced by hypotension. The first patient developed anterior ischemic optic neuropathy after excessively rapid correction of malignant hypertension. In the second patient, anterior ischemic optic neuropathy occurred after an episode of orthostatic hypotension from systemic hypovolemia. The third patient developed anterior ischemic optic neuropathy after becoming hypotensive during a routine hemodialysis session. Measures were undertaken immediately to reverse the hypotension in all three patients. This intervention resulted in partial recovery of vision in each patient.

Optic neuropathy in uraemic patients on dialysis

Optic nerve disease has been reported in patients with renal failure. A toxic aetiology has been postulated. The incidence of this complication of renal failure has not been determined. We observed 60 patients with renal failure on dialysis for 24 months to determine the incidence of optic neuropathy. Four patients developed typical acute ischaemic optic neuropathy. Their case notes were reviewed in order to determine the pathogenesis. Each patient had long-standing renal failure and its sequelae of anaemia and hypertension. The immediate causes of ischaemia were hypotension in 1, severe anaemia in 1, and generalised atherosclerosis in 2 patients.

Differences in pattern visual evoked potential (PVEP) between hemodialysis and peritoneal dialysis patients

The visual evoked potential was recorded in peritoneal and hemodialysis patients as compared to normal controls. By using the appropriate visual stimulus we were able to disclose specific VEP abnormalities for each of the two dialysis groups. The dissociation found between the latency of N70 and P100 in peritoneal dialysis patients suggests a possible postsynaptic visual abnormality not described previously. The correlation between the high serum aluminum and the P100 latency of peritoneal dialysis patients requires further investigation.

Retinal oscillatory potential abnormalities in patients with chronic renal failure, before and after dialytic treatment

Nineteen patients with chronic renal failure were studied, oscillatory potentials (OPs) being recorded shortly before and after dialytic treatment. Mean values of either onset latency (O1 latency) and duration of the complex (O1-N4 inter-peak latency) were found to be significantly longer in patients than in controls (p < 0.001). Most of the patients (12) showed a pathological prolongation of latency (> 2.5 SD). Amplitude changes also affected OPs, but earlier components were reduced to a lesser degree than the later ones, as shown by statistical analysis. Moreover, seven patients showed an almost complete loss of O3 and O4 peaks. Latency changes may be transiently reversed by dialysis, suggesting a functional impairment of the retinal response; the loss of later components is a more persistent abnormality probably related with a structural damage.