Abstract

Objective: To characterize the ocular and peri-ocular findings in patients with chronic renal failure undergoing haemodialysis at Prince Ali Bin Al- Hussein Military Hospital.

Methods: This is a descriptive study. Data were collected from patients with chronic renal failure undergoing haemodialysis from June 2012 till January 2013. The medical files were reviewed to report medical, surgical and ophthalmic history of all candidate patients. All patients underwent full ophthalmic examination on day one of recruitment. 

Results: Forty-four patients (87 eyes) were reported. Mean age was 56.9 years (56.9 ±12.5). Male to female ratio was 2:1. Aetiologies of chronic renal failure were: Hypertension (n=17, 39%), glomerulonephritis (n=13, 30%), and diabetes mellitus (n=10, 23%). Some other aetiologies were also found like: Small kidney (n=4, 9%), renal stones (n=2, 5%), polycystic kidney (n=2, 5%), familial (n=2, 5%) and analgesic nephropathy (n=1, 2%). Ocular findings were seen in 75 eyes (86%), including lid edema (n=66, 76%)), conjunctival congestion (n=54, 62%), cataract (n=47, 54%), and dry eye (n=44, 51%).

Conclusion: Ocular and peri-ocular findings were frequent in chronic renal failure patients who were undergoing hemodialysis, which urges regular ophthalmic examination to detect and treat sight threatening complications early.

Key words: Ophthalmic findings, Chronic renal failure, Hemodialysis.

JRMS September 2013; 20(3): 62-67 /DOI: 10.12816/0001043

Introduction

Chronic renal failure (CRF) is considered as one of the important health problems that affect the population. Its effect on health can be attributed to renal failure itself or the primary pathology that caused it, haemodialysis, even renal transplantation, or all of them together. It is estimated that around 10-16% of adult population in USA, Europe, Asia, and Australia are suffering from chronic renal failure.⁽¹⁾ In addition to health problems caused by CRF, management of the disease has financial impact on government treasury. Previous reports found diabetic nephropathy to be the most common cause of CRF, followed by hypertensive nephropathy and glomerulonephropathies.⁽²⁾  The association between renal diseases and visual impairment was first described by Bright in 1836. Twenty-three years later,  Liebreich described fundus changes in uremic patients and called it Bright's disease.⁽³⁾ Many studies described the high prevalence of ocular findings in patients with CRF especially in the fundus, which was blamed to be the main culprit responsible of deterioration of vision in CRF patients. A study conducted in USA by Grunwald et al. ⁽⁴⁾ revealed that the prevalence of ocular fundus pathology among CRF patients to be 45%. The above mentioned entity should be differentiated from oculorenal syndromes, which is a group of inherited and non-inherited malformations and systemic diseases that has combined ocular and renal manifestations.⁽⁵⁾ According to Jordanian Ministry of Health (MOH) statistics; 2557 Jordanian patients were reported to have CRF and scheduled for haemodialysis among all health sectors in 2011, in MOH affiliated hospitals there are 914 patients using 202 haemodialysis units and those patients underwent 123071 haemodialysis session (average 2.6 per week for each patient) in the year 2011, in Al- Karak Governorate, there are 69 patients with CRF using 14 haemodialysis units,⁽⁶⁾  according to administrative data half of those units are located in Prince Ali Military hospital and are used by 51 patients (average 2.1 per week for each patient).

Reviewing the literature, we found no report addressing the ophthalmic findings of CRF in Jordan.

Methods

This is a descriptive study where data were collected from patients with chronic renal failure undergoing haemodialysis from June 2012 till January 2013. Files were reviewed to report medical, surgical and ophthalmic history of all candidate patients. All patients underwent full ophthalmic examination on day one of recruitment. Patients with known malignancy or oculorenal syndromes were excluded. Detailed history was obtained from each patient including age, gender, past medical and surgical history, previous ocular diseases, cause of CRF, duration and frequency of haemodialysis. Detailed ophthalmologic examination included best corrected visual acuity, Schirmer’s test, eyelids, anterior segment using slit lamp biomicroscopy, intra ocular pressure measurement using Goldmann applanation tonometry, and dilated posterior segment assessment using 78 D non-contact lens. The approval of the local ethical committee was obtained as well as the patients’ consent. Data were reported and statistically analysed. 

Results

Forty-four patients (87 eyes) were included in this study, 29 of patients were males with a male to female ratio of 2:1 and the age of the patients ranged between 23 and 87 years ( mean 56.9 ±12.5 years). Patients were undergoing haemodialysis for a period ranging from two months to 22 years (mean 4.3 ±3.4 years). The primary pathologies responsible for CRF are summarized in Table I. The majority of patients had single underlying cause responsible for CRF and seven had two combined causes.

Considerable drop of vision (6/18 or less) was seen in 37 eyes (43%) and severe loss of vision (best corrected visual acuity in the best eye is less than 6/60 according to WHO classification of blindness) was seen in four patients (legally blind). Causes of decreased visual acuity among the 37 eyes are summarized in Table II.

Seventy- five eyes (86%) showed at least one eye pathology as shown in Table III. None of the eyes had elevated intraocular pressure.

Tables IV and V represent the presence of ocular pathology in relation to the duration and the frequency of dialysis, respectively.

Discussion

Chronic renal failure is a slowly progressive deterioration of renal function that usually occurs as a result of another systemic problem and result in serious systemic problems.

This study showed that males were more frequently affected than females with a ratio of 2:1 and this ratio is similar to that found in the literature. This can be explained by the rapid deterioration of renal function in some forms of glomerulonephritis and polycystic kidney disease in males.⁽⁷⁾           

Taking into consideration the prevalence of diabetes mellitus and hypertension in older age group and as these are the most important underlying causes of CRF ⁽⁸⁾ it was not surprising that the mean age of patients was 56.9 years. Most of CRF in our study was caused by hypertension, glomerulonephritis and diabetes mellitus with hypertension being the most common predisposing factor,  those results are similar to those found in many studies all over the world,⁽⁹⁾ however the second common cause was glomerulonephritis rather than diabetes mellitus, this support the idea that there is a geographical variation in the prevalence and aetiology of CRF that could be attributed to race and ethnicity, genetic predisposition, difference in prevalence of diabetes, obesity, and smoking.⁽¹⁰⁾ Another explanation could be the longer life expectancy of diabetic patients in developed countries. 

Table I: Aetiologies of CRF

Table II: Aetiologies of reduced vision among eyes with vision drop

Table III: Ocular findings among patients with CRF

Table IV: Presence of ocular pathology in relation to duration of dialysis

 Table V: Presence of ocular pathology in relation to frequency of dialysis

In this series, 37 eyes (43%) showed reduced vision, which is higher than that of a report in Nepal,⁽¹¹⁾ 23.4% of chronic renal disease patients not undergoing haemodialysis, which may explain the difference. The commonest pathology reducing vision in this series was cataract, followed by diabetic retinopathy, band keratopathy and hypertensive retinopathy respectively.  The explanation why diabetes was responsible for drop of vision more than hypertension despite hypertension prevalence among patients is that most of the diabetic retinopathies found in our patients were in advanced stages unlike hypertensive retinopathies which were present mostly in early stages.  

We reported a high incidence of ocular pathology among CRF patients on dialysis (86% of eyes). All patients with duration of dialysis more than 6 years had ocular pathology, and as the duration of haemodialysis increased the number of patients with ocular pathology or reduced vision increased, suggesting a linear relationship. This conforms to the results of Kian-Ersi et al.⁽¹²⁾ No relation was found between the frequency of dialysis sessions and the incidence of ocular pathology and reduced vision. Lid edema was the most common pathology in this series (76%).  Oedema occurs as a result of limitation in the kidneys' ability to excrete sodium into the urine, which will increase the hydrostatic pressure in the capillaries forcing the fluids to accumulate in the interstitial space. The 2^nd common ocular pathology was conjunctival congestion (62%). Causes of conjunctival congestion are associated hyperparathyroidism and elevated serum calcium concentration which deposits in conjunctiva causing severe irritation and redness.^(5,13)  Dryness was present in this series (51%). Some studies discussed this issue.^(11,13) Some explanations have been put forward. First, deposition of calcium in conjunctiva and cornea was widely suggested as aetiology due to its high association with eye dryness.⁽¹⁴⁾ In this series all patients with conjunctival and corneal calcifications and band keratopathy had dryness, and it tended to be more severe than dryness in eyes without calcifications. Dursun et al.⁽¹⁵⁾ found a considerable decrease in goblet cell density in the conjunctiva of CRF patients. Goblet cells are the primary source for synthesis of mucin layer of the tear film. William et al.⁽¹⁶⁾ suggested that dryness is more prevalent in cataract patients, which may be a third explanation for the high incidence of dryness as the incidence of cataract was high as well (43%). Pinguecula was seen in 28% of patients. This pathology is close to that found in other studies,⁽¹¹⁾ although it was present in a significant percentage, many studies showed no harmful complication of this lesion on regular follow up apart from recurrent inflammations.^(2,17) Conjunctival and corneal calcifications were present in a significant percentage of patients (9% and 7% respectively) and those calcifications mostly present within the palpebral aperture most probably due to loss of corneal and conjunctival CO₂ in these areas that results in an increase in the pH which leads to precipitation and deposition of calcium in the exposed conjunctival and cornea from the elevated serum calcium. Corneal calcification usually occurs in the periphery of the cornea but with time it extends to the centre interrupting the visual access, and called namely band keratopathy.⁽⁵⁾ This ocular pathology was responsible for 19% of reduction of vision.

Cataract was the most common cause of reduced vision (43%) as 54% of the eyes had catarctous changes and 13% were pseudophakic. This pathology is higher than in the general population. David et al ⁽¹⁸⁾ found that prevalence of cataract and pseudophakia / aphakia among adults above the age of 40 years in the United States to be 17.2% and 5.1%, respectively. This supports the assumption that CRF increases the risk of developing cataract. This may be explained by severe uremia⁽¹⁹⁾ in addition to increased levels of oxidized glutathione in CRF patients which exposes the lens to oxidative stress.⁽²⁰⁾ The higher incidence of diabetes may be another explanation. Posterior segment pathologies were the most serious because of their sight- threatening capability and the high possibility of irreversible damage to the visual system. Twenty-four eyes (28%) had at least one pathology in the fundus. The most common posterior segment abnormality was diabetic retinopathy (13%), eight eyes of which (67%) were in the form of proliferative diabetic retinopathy, while two eyes (17%) were moderate non- proliferative diabetic retinopathy, and the remaining two eyes (17%) were mild non-proliferative diabetic retinopathy. Five eyes did not show diabetic retinopathy; this means that 12 eyes out of 17 eyes (70%) of diabetic patients with CRF had diabetic retinopathy, a high percentage in comparison to previous reports in the literature.⁽²¹⁾ This may be explained by the poor control of blood sugar in Jordanian diabetics which was described in previous studies.⁽²²⁾ Hypertensive retinopathy was found in 11% of eyes and 4% had reduced vision related to diabetic retinopathy, while the remaining had changes of early grades that did not interfere with vision. Maculopathy was found in 7% of eyes. The strong relationship between nephropathy and development of proliferative diabetic retinopathy and maculapathy was shown before.^(23-26) This report demonstrated that ocular pathologies were frequent in patients with CRF on dialysis, some of which are serious and pose a threat to vision. Despite these facts, 55% of patients did not have full and detailed ocular examination. This implies lack of knowledge among patients of CRF. Therefore an effort should be adopted to increase the awareness of patients. And a protocol should be put forward by ophthalmologists and nephrologists suggesting routine ocular examination of CRF patients on haemodialysis. Potential limitations of this report include lack of fundus photography, as well as inaccurate or completely lacking medical records.

Conclusion

Ocular and peri-ocular pathologies are frequent in chronic renal failure patients who undergo hemodialysis. This urges the need for regular ophthalmic examination to detect and treat sight threatening complications as soon as these are detected. 

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