Hemodialysis and Intraocular Pressure
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It has been shown with mixed evidence that hemodialysis (HD) may transiently increase intraocular pressure (IOP), thought to caused by electrolyte and fluid shifts inherent to osmotic gradients induced by HD. This phenomenon has been described in the literature as Ocular Dialysis Disequilibrium (ODD). HD is normally well tolerated by most patients, however in a subset of patients with poorly functioning aqueous outflow tracts there may be a higher risk of exposure to transient increases in IOP during HD. This is especially concerning for patients with glaucoma who are on chronic HD. This article will discuss the literature regarding the effects of hemodialysis on IOP and explore the future aims of exploring this relatively under-studied phenomenon.
Background
Patients undergoing hemodialysis (HD) may experience an array of signs and symptoms during treatment. Early studies showed a correlation between hemodialysis and IOP spikes .[1][2] Over the years, further investigations have tried to establish a relationship between HD and IOP with varied results. [3][4][5] Although many studies have shown that HD causes transient increases in IOP, others have shown decreases in IOP during HD, and further, several have shown no significant relationship.[6] Ultimately, more research needs to be conducted to develop a more thorough understanding of risk factors that may contribute to increases in IOP during HD, especially in patients with glaucoma who are on chronic HD.
Disease
Several studies that have found positive correlations between HD and IOP in patients with and without glaucoma.[7][8][9] Most studies propose the mechanism as disequilibrium between the serum and aqueous humor as a cause for increase in IOP[10], especially the rapid decrease in plasma osmolality at the beginning of HD,[11] thus "ocular dialysis disequilibrium". This pathology is especially important to consider in patients where there may be preexisting compromise to the aqueous outflow tract or preexisting glaucoma. Patients on chronic dialysis may average around 12 hours of HD per week[12], incurring years of of exposure to increased IOP, decreased ocular perfusion pressure[9] and development or progression of glaucoma.
On the other hand, several studies have demonstrated a decrease in IOP during HD, which is proposed to be related to an increase in plasma oncotic pressure as excess fluid is removed during HD leading to and increased gradient across the uveoscleral outflow tract, facilitating aqueous outflow.[13][14]
A 2021 meta-analysis, interestingly, found no association between IOP and HD. However, subgroup analysis demonstrated that studies conducted before 1986 showed significant increases in IOP associated with HD, no change between 1986 and 2005, and a subsequent decrease after 2005. They identified the dialysate acetate as a moderator, which has generally fallen out of favor over the past several decades in favor of bicarbonate, however a history of glaucoma was also found to be a moderating factor independent of dialysate used.[15] As dialysis technologies and techniques have improved over time, the effect on IOP may be less than before, however, patients with glaucoma are still at risk of exposure to increased IOP.
Risk Factors
One study examined various biophysical parameters of the anterior chamber to explore factors that could contribute to changes in IOP before and after HD. They found that a narrow angle at baseline increases risk for IOP elevation, and various anterior angle structures such as lens thickness, angle opening distance, and trabecular-iris angle were associated with IOP changes during HD.[16]
Diagnosis
Signs/Symptoms
Many of the symptoms described in case reports during acute episodes of ocular dialysis disequilibrium include headache, photophobia, nausea, ocular pain, and periorbital pain. [17][18][19]
Differential diagnosis
Diagnosis of ODD is made clinically and is a diagnosis of exclusion. Other neurologic and ophthalmologic conditions should be ruled out, and a pattern should be established prior to making this diagnosis. These patients should be evaluated for neovascularization of the iris and of the angle with gonioscopy.
Management
Medical therapy
The general treatment is with ocular hypotensive medications, ranging from topical to systemic therapies. If symptoms are uncontrolled with medical therapy, surgical options may be considered. Comorbidities should be taken into account, as oral and parenteral medications such as acetazolamide and mannitol are relatively contraindicated in end-stage-renal-disease (ESRD), and topical beta blockers may be relatively contraindicated in patients with COPD or asthma. [20][21]
Other potential treatments include multi-disciplinary approach with collaboration with nephrology to alter the dialysis prescription. [21] Some studies suggest that advancements in HD technology "such as high-flux HD, or hemofiltration and better urea control, maintain better osmolar balance and prevent a marked IOP elevation."[22] One case reported that a higher sodium prescription resolved a patients symptoms.[21] Ultimately, ongoing multidisciplinary research is needed to establish stronger links between HD and IOP in the correct patient population, and identify multimodal treatment strategies to minimize exposure to increased IOP.
Surgery
If intra-dialytic IOP spikes are unable to be controlled with medical management, glaucoma surgery may be considered to achieve appropriate symptomatic control. One case reports the use of an Ahmed tube-shunt after maximal medical therapy was unable to achieve symptomatic control, [17] another reports use of trabeculectomy and mitomycin C.[23]
Prognosis
One large case-control study in Taiwan found that patient with ESRD were more likely to develop glaucoma with an adjusted hazard ratio of 1.270 ( 95%CI: 1.035–1.560) and had a significantly higher odds of angle-closure glaucoma with an adjusted hazard ratio of 1.550 (95% CI: 1.074–2.239).[24]
References
- ↑ Sitprija, V.; Holmes, J. H.. PRELIMINARY OBSERVATIONS ON THE CHANGE IN INTRACRANIAL PRESSURE AND INTRAOCULAR PRESSURE DURING HEMODIALYSIS. Transactions - American Society for Artificial Internal Organs 8(1):p 300-308, April 1962.
- ↑ Burn RA. Intraocular pressure during haemodialysis. Br J Ophthalmol. 1973 Jul;57(7):511-3. doi: 10.1136/bjo.57.7.511. PMID: 4725859; PMCID: PMC1214962.
- ↑ Leiba H, Oliver M, Shimshoni M, Bar-Khayim Y. Intraocular pressure fluctuations during regular hemodialysis and ultrafiltration. Acta Ophthalmol (Copenh). 1990 Jun;68(3):320-2. doi: 10.1111/j.1755-3768.1990.tb01930.x. PMID: 2392910.
- ↑ Doshiro A, Ban Y, Kobayashi L, Yoshida Y, Uchiyama H. Intraocular pressure change during hemodialysis. Am J Ophthalmol. 2006 Aug;142(2):337-9. doi: 10.1016/j.ajo.2006.03.017. PMID: 16876525.
- ↑ Levy J, Tovbin D, Lifshitz T, Zlotnik M, Tessler Z. Intraocular pressure during haemodialysis: a review. Eye (Lond). 2005 Dec;19(12):1249-56. doi: 10.1038/sj.eye.6701755. PMID: 15543171.
- ↑ Liakopoulos V, Demirtzi P, Mikropoulos DG, Leivaditis K, Dounousi E, Konstas AG. Intraocular pressure changes during hemodialysis. Int Urol Nephrol. 2015 Oct;47(10):1685-90. doi: 10.1007/s11255-015-1043-8. Epub 2015 Jul 4. Erratum in: Int Urol Nephrol. 2015 Oct;47(10):1691. doi: 10.1007/s11255-015-1086-x. PMID: 26141848.
- ↑ Maja AK, Lewis CY, Steffen E, Zegans ME, Graber ML. Increased Intraocular Pressure During Hemodialysis: Ocular Dialysis Disequilibrium. Kidney Med. 2022 Aug 1;4(9):100526. doi: 10.1016/j.xkme.2022.100526. PMID: 36043165; PMCID: PMC9420387.
- ↑ Tawara A. [Intraocular pressure during hemodialysis]. J UOEH. 2000 Mar 1;22(1):33-43. Japanese. doi: 10.7888/juoeh.22.33. PMID: 10736823.
- ↑ 9.0 9.1 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. doi: 10.1001/jamaophthalmol.2013.5599. PMID: 24232671.
- ↑ Liakopoulos V, Demirtzi P, Mikropoulos DG, Leivaditis K, Dounousi E, Konstas AG. Intraocular pressure changes during hemodialysis. Int Urol Nephrol. 2015 Oct;47(10):1685-90. doi: 10.1007/s11255-015-1043-8. Epub 2015 Jul 4. Erratum in: Int Urol Nephrol. 2015 Oct;47(10):1691. doi: 10.1007/s11255-015-1086-x. PMID: 26141848.
- ↑ Sedlacek, Martin. Ocular Disequilibrium Syndrome as a Cause of Dialysis Noncompliance: PUB130. Journal of the American Society of Nephrology 33(11S):p 920, November 2022. | DOI: 10.1681/ASN.20223311S1920c
- ↑ Key points: About Dialysis for Kidney Failure. (n.d.). National Kidney Foundation. https://www.kidney.org/key-points-about-dialysis-kidney-failure
- ↑ Kilavuzoglu AEB, Yurteri G, Guven N, Marsap S, Celebi ARC, Cosar CB. The effect of hemodialysis on intraocular pressure. Adv Clin Exp Med. 2018 Jan;27(1):105-110. doi: 10.17219/acem/68234. PMID: 29521050.
- ↑ Doshiro A, Ban Y, Kobayashi L, Yoshida Y, Uchiyama H. Intraocular pressure change during hemodialysis. Am J Ophthalmol. 2006 Aug;142(2):337-9. doi: 10.1016/j.ajo.2006.03.017. PMID: 16876525.
- ↑ Chen SH, Lu DW, Ku WC, Chuang LH, Ferng SH, Chen YJ, Lu YH, Chai PY. Changes in Intraocular Pressure During Hemodialysis: A Meta-analysis. J Glaucoma. 2021 Sep 1;30(9):866-873. doi: 10.1097/IJG.0000000000001842. PMID: 33813568.
- ↑ Wang F, Wang L, Yu Z, Chen N, Wang D. Effects of Hemodialysis on Intraocular Pressure and Ocular Biological Parameters in Different Angle Structures. Dis Markers. 2022 Feb 12;2022:9261653. doi: 10.1155/2022/9261653. PMID: 35190757; PMCID: PMC8858050.
- ↑ 17.0 17.1 Maja AK, Lewis CY, Steffen E, Zegans ME, Graber ML. Increased Intraocular Pressure During Hemodialysis: Ocular Dialysis Disequilibrium. Kidney Med. 2022 Aug 1;4(9):100526. doi: 10.1016/j.xkme.2022.100526. PMID: 36043165; PMCID: PMC9420387.
- ↑ Babiker S, Elsayed ME, Dhaygude A, Madgula I. A complex case of haemodialysis induced increased intraocular pressure. Eur J Ophthalmol. 2019 Jul;29(1_suppl):15-17. doi: 10.1177/1120672119842481. Epub 2019 Apr 24. PMID: 31014077.
- ↑ Lim SH, Son J, Cha SC. Recurrent symptomatic intraocular pressure spikes during hemodialysis in a patient with unilateral anterior uveitis. BMC Ophthalmol. 2013 Feb 6;13:3. doi: 10.1186/1471-2415-13-3. PMID: 23384186; PMCID: PMC3577671.
- ↑ Acetazolamide: Considerations for Systemic Administration. (2015, March 1). Chak, G., Patel, R., Allingham, R. American Academy of Ophthalmology. https://www.aao.org/eyenet/article/acetazolamide-considerations-systemic-administrati
- ↑ 21.0 21.1 21.2 Lippold CL, Kalarn SP, Swamy RN, Patel AM. Ocular dialysis disequilibrium-Management of intraocular pressure during hemodialysis of open angle glaucoma: A case report and review of the literature. Hemodial Int. 2019 Jul;23(3):E72-E77. doi: 10.1111/hdi.12718. Epub 2019 Feb 20. PMID: 30785657.
- ↑ Liakopoulos V, Demirtzi P, Mikropoulos DG, Leivaditis K, Dounousi E, Konstas AG. Intraocular pressure changes during hemodialysis. Int Urol Nephrol. 2015 Oct;47(10):1685-90. doi: 10.1007/s11255-015-1043-8. Epub 2015 Jul 4. Erratum in: Int Urol Nephrol. 2015 Oct;47(10):1691. doi: 10.1007/s11255-015-1086-x. PMID: 26141848.
- ↑ Lim SH, Son J, Cha SC. Recurrent symptomatic intraocular pressure spikes during hemodialysis in a patient with unilateral anterior uveitis. BMC Ophthalmol. 2013 Feb 6;13:3. doi: 10.1186/1471-2415-13-3. PMID: 23384186; PMCID: PMC3577671.
- ↑ Lim CC, Lee CY, Huang FC, Huang JY, Hung JH, Yang SF. Risk of Glaucoma in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Nationwide Population-Based Cohort Study. Int J Environ Res Public Health. 2020 Sep 17;17(18):6774. doi: 10.3390/ijerph17186774. PMID: 32957502; PMCID: PMC7559152.
