Eye disorders associated with chronic kidney disease
- Eli A Friedman, MD
Eli A Friedman, MD
- Distinguished Teaching Professor of Medicine
- Downstate Medical Center, Brooklyn, New York
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
Medical supervision of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) seldom requires specific attention to the eyes. An important exception is the need for perpetual surveillance, in collaboration with an ophthalmologist, of all dialysis patients with diabetes, in whom the risk of vision loss is substantial.
Disorders of the kidney rarely directly affect vision or change the anatomic integrity of the eyes. Recognition of a coincident eye problem during evaluation of kidney disease is usually fortuitous. As an example, advanced proliferative diabetic retinopathy can be completely asymptomatic. At the other extreme, complaints about vision may lead to the diagnosis of a previously unsuspected kidney disease. The presence of Alport syndrome, for example, may be detected when corneal erosion or anterior lenticonus is found during the assessment for blurred vision.
OPHTHALMOSCOPIC EVALUATION AND GENERAL FINDINGS IN CHRONIC KIDNEY DISEASE AND END-STAGE RENAL DISEASE
A comprehensive study of a patient with CKD or end-stage kidney disease (ESRD) should include examination of the external eye and direct ophthalmoscopy. Benefits of this approach were noted in a multicenter, cross-sectional longitudinal study of 1936 individuals with varying stages of CKD in which 45 degree digital photos of the disc and macula in both eyes, obtained by nonophthalmologic personnel, were assessed in a masked manner by a retinal specialist . A total of 1904 subjects (98 percent) had satisfactory photographs of at least one eye, of which eye "pathologies" requiring follow-up examination by an ophthalmologist were identified in 864 (45 percent). These pathologies included serious eye conditions requiring urgent treatment in 65 participants (3 percent) and diabetic and/or hypertensive disease in 482 (25 percent). An estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 was associated with a three times higher risk for retinopathy than a normal GFR. Further study of retinal photographs from the same patients, termed the Chronic Renal Insufficiency Cohort (CFIC) study group , noted that 45 percent had pathologic changes requiring ophthalmologic follow-up, while 3 percent had serious retinal findings requiring urgent treatment. ESRD may lead to retinal detachments as a consequence of tears or breaks in the retina through which liquefied vitreous fluid leaks into the subretinal space as reported in three patients . Advanced kidney disease of any etiology induces eye findings that signal the need for initiation or intensification of therapy. As examples:
●Conjunctival erythema, termed the red eyes of uremia, may be noted when high plasma phosphate levels induce corneal and conjunctival precipitation of calcium pyrophosphate.
●Metastatic calcification in the eyes may be associated with elevations of the serum concentration of calcium or calcium-phosphate product .
- Grunwald JE, Alexander J, Maguire M, et al. Prevalence of ocular fundus pathology in patients with chronic kidney disease. Clin J Am Soc Nephrol 2010; 5:867.
- Grunwald JE, Alexander J, Ying GS, et al. Retinopathy and chronic kidney disease in the Chronic Renal Insufficiency Cohort (CRIC) study. Arch Ophthalmol 2012; 130:1136.
- Wong MH, Cheung GC, Chee SP, Mathur R. Exudative detachment as a masquerader in hypoalbuminaemic patients. Clin Kidney J 2014; 7:406.
- Hsiao CH, Chao A, Chu SY, et al. Association of severity of conjunctival and corneal calcification with all-cause 1-year mortality in maintenance haemodialysis patients. Nephrol Dial Transplant 2011; 26:1016.
- Tyler HR. Neurologic disorders seen in the uremic patient. Arch Intern Med 1970; 126:781.
- Jarosz JM, Howlett DC, Cox TC, Bingham JB. Cyclosporine-related reversible posterior leukoencephalopathy: MRI. Neuroradiology 1997; 39:711.
- Merimsky O, Nisipeanu P, Loewenstein A, et al. Interferon-related cortical blindness. Cancer Chemother Pharmacol 1992; 29:329.
- Berlyne GM, Shaw AB. Red eyes in renal failure. Lancet 1967; 1:4.
- Gofman L, Süle T, Agoston I. Red eyes in renal disease. Acta Med Acad Sci Hung 1973; 30:53.
- Klaassen-Broekema N, van Bijsterveld OP. Diffuse and focal hyperaemia of the outer eye in patients with chronic renal failure. Int Ophthalmol 1993; 17:249.
- Tokuyama T, Ikeda T, Sato K, et al. Conjunctival and corneal calcification and bone metabolism in hemodialysis patients. Am J Kidney Dis 2002; 39:291.
- Cohen SL, Gorchein A, Hayward JA, et al. Pingueculae--an association with renal failure. Q J Med 1974; 43:281.
- Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol 1988; 33:41.
- Nakaishi H, Yamamoto M, Ishida M, et al. Pingueculae and pterygia in motorcycle policemen. Ind Health 1997; 35:325.
- Chugh SK, Goel A. Bilateral cataracts as the presenting manifestation of chronic renal failure. J Assoc Physicians India 1992; 40:273.
- Straub W, Freund J. [Cataract after extracorporal dialysis therapy]. Klin Monbl Augenheilkd 1970; 157:50.
- Laqua H. [Cataract in chronic renal insufficiency and dialysis]. Klin Monbl Augenheilkd 1972; 160:346.
- Koch HR, Siedek M, Weikenmeier P, Metzler U. [Cataract during intermittent hemodialysis. The influence of hypocalcemia on the development of opacities (author's transl)]. Klin Monbl Augenheilkd 1976; 168:346.
- Centers for Disease Control and Prevention (CDC). Prevalence of visual impairment and selected eye diseases among persons aged >/=50 years with and without diabetes--United States, 2002. MMWR Morb Mortal Wkly Rep 2004; 53:1069.
- Liew G, Mitchell P, Wong TY, et al. CKD increases the risk of age-related macular degeneration. J Am Soc Nephrol 2008; 19:806.
- Pelit A, Zümrütdal A, Akova Y. The effect of hemodialysis on visual field test in patients with chronic renal failure. Curr Eye Res 2003; 26:303.
- Bansal S, Ansons A, Vishwanath M. Hypotension-induced blindness in haemodialysis patients. Clin Kidney J 2014; 7:387.
- Hattenhauer MG, Leavitt JA, Hodge DO, et al. Incidence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1997; 123:103.
- Lim JH, Kim IT. The electroretinogram in chronic renal failure. Korean J Ophthalmol 1998; 12:68.
- Resende LA, Caramori JC, Kimaid PA, Barretti P. Blink reflex in end-stage-renal disease patients undergoing hemodialysis. J Electromyogr Kinesiol 2002; 12:159.
- Danpure CJ. The molecular basis of alanine: glyoxylate aminotransferase mistargeting: the most common single cause of primary hyperoxaluria type 1. J Nephrol 1998; 11 Suppl 1:8.
- Giafi CF, Rumsby G. Primary hyperoxaluria type 2: enzymology. J Nephrol 1998; 11 Suppl 1:29.
- Lasram L, Kammoun A, Karray T, et al. [Ocular signs of primary hyperoxaluria type I]. J Fr Ophtalmol 1997; 20:258.
- De Laey JJ. Flecked retina disorders. Bull Soc Belge Ophtalmol 1993; 249:11.
- Espaillat A, Aiello LP, Arrigg PG, et al. Canthaxanthine retinopathy. Arch Ophthalmol 1999; 117:412.
- Flinter F. Alport's syndrome. J Med Genet 1997; 34:326.
- Rhys C, Snyers B, Pirson Y. Recurrent corneal erosion associated with Alport's syndrome. Rapid communication. Kidney Int 1997; 52:208.
- Bekheirnia MR, Reed B, Gregory MC, et al. Genotype-phenotype correlation in X-linked Alport syndrome. J Am Soc Nephrol 2010; 21:876.
- Tsilou ET, Rubin BI, Reed GF, et al. Age-related prevalence of anterior segment complications in patients with infantile nephropathic cystinosis. Cornea 2002; 21:173.
- Das T, Gupta A, Sakhuja V, et al. Ocular complications in renal allograft recipients. Nephrol Dial Transplant 1991; 6:649.
- Veenstra DL, Best JH, Hornberger J, et al. Incidence and long-term cost of steroid-related side effects after renal transplantation. Am J Kidney Dis 1999; 33:829.
- Matsunami C, Hilton AF, Dyer JA, et al. Ocular complications in renal transplant patients. Aust N Z J Ophthalmol 1994; 22:53.
- Suppiah R, Abraham G, Sekhar U, et al. Nocardial endophthalmitis leading to blindness in a renal transplant recipient. Nephrol Dial Transplant 1999; 14:1576.
- Biswas J, Gopal L, Sharma T, et al. Recurrent cryptococcal choroiditis in a renal transplant patient: clinicopathologic study. Retina 1998; 18:273.
- Başçil N, Erdem Y, Yalçin AU, et al. Evisceration of the eye in a renal transplant recipient with cytomegalovirus chorioretinitis. Am J Nephrol 1996; 16:367.
- Algan M, Jonon B, George JL, et al. Listeria monocytogenes endophthalmitis in a renal-transplant patient receiving ciclosporin. Ophthalmologica 1990; 201:23.
- Lopez V, Sola E, Gutierrez C, et al. Anterior uveitis associated with treatment with intravenous cidofovir in kidney transplant patients with BK virus nephropathy. Transplant Proc 2006; 38:2412.
- Ohkubo H. Several functional and fluorescein fundus angiographic findings in Fabry's disease. Ophthalmologica 1988; 196:132.
- Sher NA, Letson RD, Desnick RJ. The ocular manifestations in Fabry's disease. Arch Ophthalmol 1979; 97:671.
- Diaz-Buxo JA, Burgess WP, Greenman M, et al. Visual function in diabetic patients undergoing dialysis: comparison of peritoneal and hemodialysis. Int J Artif Organs 1984; 7:257.
- Porter JB, Huehns ER. The toxic effects of desferrioxamine. Baillieres Clin Haematol 1989; 2:459.
- Ravelli M, Scaroni P, Mombelloni S, et al. Acute visual disorders in patients on regular dialysis given desferrioxamine as a test. Nephrol Dial Transplant 1990; 5:945.
- Hojs R, Pahor D. Intraocular pressure in chronic renal failure patients treated with maintenance hemodialysis. Ophthalmologica 1997; 211:325.
- Austin JN, Klein M, Mishell J, et al. Intraocular pressures during high-flux hemodialysis. Ren Fail 1990; 12:109.
- Tokuyama T, Ikeda T, Ishikawa H, Sato K. Marked decrease in intraocular pressure in a neovascular glaucoma patient during hemodialysis. Jpn J Ophthalmol 1997; 41:101.
- Smith JR, Mackensen F, Rosenbaum JT. Therapy insight: scleritis and its relationship to systemic autoimmune disease. Nat Clin Pract Rheumatol 2007; 3:219.
- Bennett B, Booth T, Quan A. Late onset seizures, hemiparesis and blindness in hemolytic uremic syndrome. Clin Nephrol 2003; 59:196.
- Izzedine H, Bodaghi B, Launay-Vacher V, Deray G. Oculorenal manifestations in systemic autoimmune diseases. Am J Kidney Dis 2004; 43:209.
- Ghanem RC, Chang N, Aoki L, et al. Vasculitis of the lacrimal sac wall in Wegener granulomatosis. Ophthal Plast Reconstr Surg 2004; 20:254.
- OPHTHALMOSCOPIC EVALUATION AND GENERAL FINDINGS IN CHRONIC KIDNEY DISEASE AND END-STAGE RENAL DISEASE
- Red eyes
- Age-related macular degeneration
- SYSTEMIC DISORDERS ASSOCIATED WITH OCULORENAL FINDINGS
- Alport syndrome
- Kidney transplantation
- Fabry disease
- Diabetes mellitus
- Deferoxamine toxicity
- Autoimmune diseases