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  5. FP586 : A Clinical Study on Effects of Haemodialysis on Intra Ocular Pressure

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Dr. Asma Shaik, S16172, Dr.Vivek Praveen Kumar K

 INTRODUCTION

The individuals suffering from chronic kidney disease (CKD) are usually treated by hemodialysis, a blood filtration mechanism. A quarter of patients of CKD needing hemodialysis are usually elderly, more than 60 years age [1]. Hemodialysis alters various metabolic parameters like urea, glucose, electrolytes like sodium and potassium levels.  These metabolic changes result in alteration in the composition of ocular fluids there by affecting various ocular parameters including Intraocular pressure (IOP)[2]. As age is an important risk factor for the development of glaucoma, elderly patients undergoing hemodialysis would more likely develop glaucoma with changes in IOP during the procedure. Oxygenation of ocular tissues depends on maintenance of ocular perfusion pressure (OPP) through systemic regulation of blood pressure (BP) and local regulation of IOP. Vascular dysregulation leads to abnormal ocular perfusion and thus optic nerve ischemia, leading to glaucomatous damage.Conflicting reports exist on the effect of hemodialysis on IOP. A number of studies have reported an increase in IOP following hemodialysis [3,4,5] where as few studies have reported decrease in IOP following hemodialysis [6,7,8].Some studies have shown no effect of hemodialysis on IOP [9,10].  A thorough review of literature showed no studies in Indian patients and hence a study was planned to assess the effects of hemodialysis on IOP.

MATERIALS AND METHODS This was a prospective study conducted in the department of ophthalmology of tertiary care hospital in South India. Informed written consent was obtained from all the participants. Institute ethical committee approval was obtained for the study. All patients with end stage renal disease diagnosed by the nephrologist undergoing hemodialysis were included in the study. The characterstics of hemodialysis were as follows: Conventional hemodialysis, two sessions per week,  each session lasting three hours, using Fresenius machine. The dialysate used was heparin free citrate and sodium bicarbomate . The blood flow rate was 250-300 ml/hr.A total of 70 patients undergoing hemodialaysis were included in the study. Patients on anti glaucoma treatment or those who have had earlier laser or any ocular surgery, patients with evidence of uveitis, contact lens users or any infections of the eye were excluded from the study. Detailed history   including demographic data, number of years of chronic kidney disease, number of years of hemodialysis, status of diabetes, hypertension,  were collected from all the patients included in the study. . The  concentration of the electrolytes sodium, potassium, chloride, calcium, phosphorous and levels of alkaline phopshatase, alteration of weight following the procedure, amount of ultrafiltrate were also recorded. All patients underwent ophthalmic examination before the commencement of dialysis including gonioscopy to see the status of the angles. IOP was measured just before the start of the dialysis and one hour after the completion of the procedure. IOP was measured using Schiotz tonometer as goldmannapplanation tonometry needs the patient to be in sitting position for recording the IOP. MAjoirty of patients have hypotension following hemodialysis and hence were not able to sit and hence schiotz tonometer was used to record the IOP.  All the results were tabulated and analaysed. Statistical analysis was done with p value less than 0.05 to be significant.

RESULTS A total of 140 eyes of 70 patients were included in our study. Out of 70 patients in the study, 17 (24.3%) patients were less than 40 yrs of age and 53(75.7%) patients were above 40 yrs of age.53(75.7%) patients were males and 17(24.3%) patients were females. 22 (31.4%) patients were diabetics and 48(68.6%) patients were non- diabetics. 61(87.1%) patients were hypertensive and 9(12.9%) patients were normotensive. The mean IOP before haemodialysis in right eye (RE) was 16.59+/-2.44 mmHg and in left eye (LE) was 16.67+/-2.625mmHg. The mean IOP after haemodialysis in RE was 19.23+/-2.788mmHg and in LE was 19.64+/-3.42mmHg.The intraocular pressure raised after haemodialysis, with mean IOP rise in RE being 2.64 +/- 2.72 SD ( p<0.0001) and in LE being 2.97+/-3.57SD (p<0.0001) which was found to be statistically significant. In patients less than 40 years age, the mean IOP in right eye before dialysis was 16.53 1.663mmHg and after dialysis was 18.41+/- 2.399mmHg where as in patients above 40 years of age, the mean IOP in right eye before dialysis was 16.60+/- 2.65mmHg and after hemodialysiswas 19.49+/- 2.87mmHg. In patients less than 40 years age, the mean IOP in Left eye before dialysis was 16.18+/- 2.72mmHg and after dialysis was 18.29+/- 2.71mmHg where as in patients above 40 years of age, the mean IOP in left eye before dialysis was 16.83+/- 2.60mmHg and after hemodialysis was 20.08+/- 3.54 mmHg. There was no statistically significant difference in mean IOP rise in patients less than 40years of age compared to patients more than 40 years of age. When the mean IOP rise post dialysis was compared between males and females, there was no statistically significant difference. The mean IOP in right eye before dialysis was 16.77+/- 2.49mm Hg and after hemodialysis was 19.39+/- 2.78 mm Hg in hypertensive patients where as in normotensive patients the mean IOP before dialysis was 15.33+/- 1.58 mm Hg and after dialysis was 18.11+/- 2.73 mm Hg. The mean IOP in left eye before dialysis was 17.00+/- 2.55 mm Hg and after dialysis was 19.69+/- 3.13 mm Hg in hypertensives and in normotensives the mean IOP before dialysis was 14.44 +/-2.00 mm Hg and after dialysis was 19.33+/- 5.22 mm Hg. There was no statistically significant difference in mean IOP rise in hypertensive versus normotensive patients. The mean IOP in right eye before dialysis was 16.36+/- 2.92 mmHg and after dialysis was 19.41+/- 2.806mmHg in diabetic patients where as in non- diabetic patients the mean IOP before dialysis was 16.69+/- 2.21mmHg and after dialysis mean IOP was 19.15+/- 2.806mmHg. The mean IOP in left eye before dialysis was 16.77+/- 2.707 and after hemodialysis was 19.95+/- 2.627mmHgin diabetic patients where as in non- diabetic patients the mean IOP before dialysis was 16.63+/- 2.61mmHg and after dialysis was 19.50+/- 3.75mmHg.There was no statistically significant difference in mean IOP rise in diabetic versus non- diabetic patients. Avery low correlation was found between IOP and with other systemic parameters like calcium, phosphorus, urea, creatinine, alkaline phosphatise.

DISCUSSION

Equilibrium between continuous secretion of aqueous humour inside the eye from nonpigmented epithelium of cilliary body and its drainage from anterior chamber angle maintains  an acceptable intraocular pressure that is normally between 10 mm Hg and 21 mm Hg. [11].

Effects of hemodialysis on IOP have been a challenging issue in the medical literature and different hypothesis has been outlined in this topic.[13,14] Factors involving IOP changes in hemodialysis are still not completely understood and various mechanisms have been postulated.

Dysfunctional regulation of ocular blood flow due to atherosclerosis, vasospasm and vascular endothelial dysfunction existing in these patients makes the ESRD patients more susceptible to IOP changes and glaucomatous disc damage[12]. Decrease in plasma osmolality, Increase in the concentration of urea in the aqueous humor were the earlier postulated mechanisms of rise in IOP during hemodialysis[16,17].

If the outflow system is normal, there occurs only a small rise in IOP. Provided that the eye-outflow system is normal, the rise is small, where as in eyes with eye-outflow obstruction secondary  to occludable angles or peripheral anterior synechiae, the IOP may rise sharply during the procedure leading  to acute angle closure glaucoma.

Levy and colleagues described that although the effect of hemodialysis on IOP is unclear and even opposite findings may be encountered, in patients with glaucomatous eye, features of an acute rise in IOP are seen more frequently than normal individuals and future studies has been recommended. [15] In general, findings of this study revealed that there were meaningful inverse relationship between blood glucose level changes and IOP changes during hemodialysis. There were no significant relationship between changes in the IOP and serum sodium and potassium, blood pressure, blood urea, KT/V, weight, duration of hemodialysis, and underlying diseases before and after hemodialysis.

Tokuyama et al evalauted the relationship between IOP and plasma colloid osmotic pressure and found a correlation  between change in IOP during HD and plasma colloid oncotic pressure[19].

According to  Burn IOP rise during HD occurs due to cerebral oedema consequent to the  rapid drop in serum osmolality[4].

Rever et al  found that IOP did not change following a 4-h HD session with either acetate or bicarbonate in the dialysate. Acetate HD may result in a longer period of acidosis whereas bicarbonate HD, which is associated with a steadily rising blood pH, rapidly corrects the intraocular acidosis and thus permit normal aqueous dynamics to proceed. They concluded that acetate dialysis might adversely affect ocular dynamics in susceptible patients with glaucoma[18].

Tovbin et al implied post dialysis urea rebound (PDUR) in changes of IOP during HD. During the  procedure, urea removal from the cellular compartment lapses behind its removal from the extracellular compartment, thus creating a gap between cellular and serum urea levels. This gap is reversed by postdialysis urea exit from cells to the extracellular fluid, which is reflected by PDUR. This gap induces intradialysis water movement from the extracellular fluid to the intracellular compartments[3].

Out of 70 patients in the study, 17 (24.3%) patients were less than 40 yrs of age and 53(75.7%) patients were above 40 yrs of age. This is because of the fact that majority of patients of chronic kidney disease are usually elderly[1].

In the present study , IOP rise was seen in 132 eyes out of 140 eyes and only 8 eyes did not show an increase in IOP .The mean IOP before haemodialysis in right eye (RE) was 16.59+/-2.44 mmHg and in left eye (LE) was 16.67+/-2.625mmHg. The mean IOP after haemodialysis in RE was 19.23+/-2.788mmHg and in LE was 19.64+/-3.42mmHg.The intraocular pressure raised after haemodialysis, with mean IOP rise in RE being 2.64 +/- 2.72 SD ( p<0.0001) and in LE being 2.97+/-3.57SD (p<0.0001) which was found to be statistically significant. Our findings correlate with other studies which showed an increase in IOP following hemodialysis.

The mean IOP in right eye before dialysis was 16.36+/- 2.92 mmHg and after dialysis was 19.41+/- 2.806mmHg in diabetic patients where as in non- diabetic patients the mean IOP before dialysis was 16.69+/- 2.21mmHg and after dialysis mean IOP was 19.15+/- 2.806mmHg. The mean IOP in left eye before dialysis was 16.77+/- 2.707 and after hemodialysis was 19.95+/- 2.627mmHgin diabetic patients where as in non- diabetic patients the mean IOP before dialysis was 16.63+/- 2.61mmHg and after dialysis was 19.50+/- 3.75mmHg. There was no statistically significant difference in mean IOP rise in diabetic versus non- diabetic patients. We did not find any differences in IOP rise between diabetic and non diabetic patients. This is in contrast to study by Afshar et al who found an inverse relation between IOP and blood glucose[20]. The exact cause of this variability cannot be clearly explained as the IOP changes during hemodialysis are multifactorial.

A very low correlation was found between IOP and with other systemic parameters like calcium, phosphorus, urea, creatinine, alkaline phosphatase. This finding is in accordance with the study by Afsar et al who also did not find correlation between the changes in IOP and other mentioned parameters[20]. The IOP rise in our study was seen in 132 eyes out of 140 eyes. Gonisocopy was deferred in our study owing to the systemic condition of the patients included in the study. It is unlikely that all the patients included in the study would have had occludable angles and the results of our study shows that IOP rise after hemodialysis is independent of the status of the angle. The results of the present study are in contrast of those by De Marchi et al who reported that in patients with narrow angles there was rise in IOP where as in those with open angles there was no rise in IOP[21].. The patients in our study showed a rise in IOP despite bicarbonate dialysate. This is in contrast to the study by Rever et al who compared bicarbonate and acetate and found no significant rise in IOP with bicarbonate dialysate[18]. The present study has its own limitations. Firstly the IOP in the study was measured with Schiotz tonometer as it is prone to artefacts by abnormal ocular rigidity as seen in myopic eyes and the refractive status of the eyes was not considered in the study. Further gonioscopy was not done to know the status of the angle which would have helped us to know whether the IOP rise is independent of the status of the angle. IOP was measured only at the start and at the end of the procedure but not during the procedure.

CONCLUSION

IOP increase during HD is a frequent or infrequent complication remains still a matter of debate. A close collaboration of ophthalmologists and nephrologists is needed for treatment of possible acute IOP rises and for long follow-up and prevention of possible optic nerve damage in these patients.  The possibility of an obstruction of aqueous humour outflow should be kept in mind in eyes showing a significant increase of IOP during HD. These patients need a close follow up as they are likely to have greater IOP variations  during or after the procedure. Further research needs to be done on this issue which will help us to devlop better protocols to prevent IOP rise in these patients. The team treating the HD patient should be alert on possible ocular symptoms of acute IOP rise, such as blurred vision, eye pain, headache, or signs like mid-dilated pupil and corneal oedema, and consult the ophthalmologist in case of suspected IOP increase.

REFERENCES

  1. Hu J, Bui KM, Patel KH, Kim H, Arruda JA, Wilensky JT, Vajaranant TS. Effect of hemodialysis on intraocular pressure and ocular perfusion pressure. JAMA Ophthalmol. 2013 Dec;131(12):1525-31
  2. Vrabec R, Vatavuk Z, Pavlović D, et al. Ocular findings in patients with chronic renal failure undergoing haemodialysis. 2005;29(Suppl 1):95–98.
  3. Tovbin D, Belfair N, Shapira S, Rosenthal G, Friger M, Feldman L et al.High postdialysis urea rebound can predict intradialytic increase in intraocular pressure in dialysis patients with lowered intradialytichemoconcentration. Nephron 2002; 90: 181–187
  4. Burn RA. Intraocular pressure during hemodialysis. Br J Ophthalmol1973; 57: 511–513
  5. Tawara A, Kobata H, Fujisawa K, Abe T, Ohnishi Y. Mechanism of intraocular pressure elevation during hemodialysis. Curr Eye Res1998; 17: 339–347.
  6. Yang SJ, Han YH, Song GI, Lee CH, Sohn SW. Changes of choroidalthickness,intraocular pressure and other optical coherence tomographic parameters afterhaemodialysis. ClinExpOptom. 2013 Sep;96(5):494-9.7.
  7. Jung JW, Yoon MH, Lee SW, Chin HS. Effect of hemodialysis (HD) on intraocular pressure, ocular surface, and macular change in patients with chronic renalfailure. Effect of hemodialysis on the ophthalmologic findings. Graefes Arch ClinExpOphthalmol. 2013 Jan;251(1):153-62.8.
  8. Doshiro A, Ban Y, Kobayashi L, Yoshida Y, Uchiyama H. Intraocular pressurechange during hemodialysis. Am J Ophthalmol. 2006 Aug;142(2):337-99.
  9.    Austin JN, Klein M, Mishell J, Contiguglia SR, Levy J, Chan L et al. Intraocular pressure during high-flux hemodialysis. Renal Failure 1990; 12: 109–11210.
  10. Pelit A, Zumrutdal A, Akova Y. The effect of hemodialysis on visual field test in patients with chronic renal failure. Curr Eye Res 2003; 26: 303–30611.
  11. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open-angle glaucoma in Australia. The Blue Mountains Eye Study. Ophthalmology 1996;103:1661-9.
  12. Moore D, Harris A, Wudunn D, Kheradiya N, Siesky B. Dysfunctional regulation of ocular blood flow: A risk factor for glaucoma? ClinOphthalmol. 2008;2:849-61
  13. Dinc UA, Ozdek S, Aktas Z, Guz G, Onol M. Changes in intraocular pressure, and corneal and retinal nerve fiber layer thickness during hemodialysis. IntOphthalmol. 2010;30:337-40
  14. Samsudin A, Mimiwati Z, Soong T, Fauzi MS, Zabri K. Effect of haemodialysis on intraocular pressure. Eye (Lond). 2010;24:70-3
  15. . Levy J, Tovbin D, Lifshitz T, Zlotnik M, Tessler Z. Intraocular pressure during haemodialysis: a review. Eye (Lond). 2005;19:1249-56.
  16. Sitprija V, Holmes JH, Ellis PP. Intraocular pressure changes during artificial kidney therapy. Arch Ophthalmol1964; 72: 626–631)
  17. Watson SG, Greenwood WR. Studies on the intraocular pressure during hemodialysis. Can J Ophthalmol1966; 1: 301–307
  18. Rever B, Fox L, Bar-Khayim Y, Nissenson A. Adverse ocular effects of acetate hemodialysis. Kidney Int1981; 19: 157
  19. Tokuyama T, Ikeda T, Sato K. Effect of plasma colloid osmotic pressure on intraocular pressure during hemodialysis. Br J Ophthalmol1998; 82: 751–753
  20. Afshar R, Ghasemi H, Shabpiray H, Abdi S, Davati A, Zerafatjou N, KhorsandAskari M. Monitoring of intraocular pressure and its correlation with systemic parameters before and after hemodialysis. Iran J Kidney Dis. 2013 Jan;7(1):53-9
  21. De Marchi S, Cechin E, Tesio F. Intraocular pressure changes during hemodialysis: prevention of excessive dialytic rise and development of severe metabolic acidosis following acetazolamide therapy. Renal Failure1989; 11: 117–124

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