Can dialysis affect my vision?

[okarol]

Can dialysis affect my vision?

Answer: Yes, although rare, there have been reports of patients with changes in visual perception when starting dialysis. Eyeglass prescriptions were changed to ensure vision did not change.1 For most people on dialysis, blurred vision or changes in visual sharpness were not primarily caused by dialysis. The eye can be considered a digital video camera. It collects light through a lens, sending it through a fluid substance called the vitreous to the back of the eye, where it is focused on a photosensitive plate called the retina. From here, impulses travel along optic nerves to the back of the brain, where the photographic image is assembled. The circulation feeds this whole system, and the blood pressure must be supported. The eye can become infected with bacteria, viruses and other organisms. Tumors can infiltrate at any point along the path. Any change in composition of fluid in the eye (diabetic-induced fluid shifts) can cause changes in visual sharpness. Inflammation can also lead to eye conditions.

Eyesight is precious and early attention to even the slightest disorder in vision may prevent its loss. If vision becomes blurred, one should notify their doctor. After a careful history, further eye and physical examinations may be needed. There are many causes of blurred vision, some very mild, but others severe. Here is a review:

Anterior Ischemic Optic Neuropathy

This can occur when circulation to portions of the optic nerve are involved. Dialysis patients have many predisposing conditions, such as atherosclerosis, hypotension, hypertension and anemia. Early findings may be blurred vision, which can cause vision loss in one eye or both.2

Syncope

This happens when blood supply to the brain is suddenly interrupted, occasionally during dialysis because the blood pressure drops. Blurred vision may be an early symptom, along with headache, weakness, nausea or vomiting. Diabetics can have impairment in the neurological system that controls blood pressure, and may be very sensitive to changed position from sitting to standing, thus susceptible to syncope.3

Retinal Detachment

Blurred vision is a late finding in diabetic retinopathy. Patients with diabetes should have yearly eye examinations. If retinopathy is present, one should be evaluated for laser therapy.4

Macular Degeneration

This is a serious eye disorder with blurred vision, particularly when reading, that starts later in life. The macula is a concentrated area on the retina that allows color and fine detail vision. If cells in this area lose function, it may impair eyesight. Early management is essential. Regular eye doctor visits and attentiveness to symptoms can detect macular degeneration early.5 Click here for more information.

Dry Eye

This may have many causes that culminate in disorders of making tears. Sometimes artificial tears and ointments are necessary. Good lid hygiene is also important.6

Tumors, Aneurysms and Cysts

This can infiltrate nerves or the brain and interfere with eye function. They have complex names, such as prolactinoma, schwannoma, lymphoma, myeloma, meningioma, leukemia, melanoma, colloid cysts and cavernous sinus aneurysms. Blurred vision may be an early sign, but usually other symptoms develop depending upon the location.

Pseudotumor Cerebri (False Brain Tumor)

Brain tumors can cause increased pressure inside the cranium. This may cause a change in the eye known as papilledema. Blurred vision is an early finding, but is potentially blinding.7

Hypoglycemia (Low Blood Sugar)8 and Thyroid Disease9

These endocrine disorders are associated with blurred vision.

Infections, Viruses, Bacteria, and Other Organisms

These can invade the eye or brain. Orbital cellulitis (an acute infection of the orbit), where the eye sits, can be very dangerous because of its rapid spread and proximity to the brain. It can respond to immediate antibiotics. Blurred vision can be associated with fever, headache, pain and swollen or red eyelids. A CT scan will diagnosis this. It can be related to sinusitis. Some eye infections, such as toxoplasmosis, are rare in the United States, but well known in other parts of the world, such as Indonesia.10 Botulism11 is a rare, rapidly fatal form of food poisoning caused by a very dangerous bacterial toxin. It can present with blurred vision. Some infectious diseases, such as CMV retinitis can occur in immunocompromised persons.12 Creutzfeldt (Jakob disease), a very rare form of dementia can potentially occur from bovine spongioform encephalopathy (Mad Cow Disease). Although blurred vision is noticed, it is associated with other symptoms, such as trouble walking or talking and eventually dementia.13, 14, 15

It is no surprise many forms of inflammation can cause eye symptoms. Systemic diseases that occur in distant parts of the body can have manifestations, such as uveitis. Uveitis is inflammation of the uveal tract (several areas in the front of the eye). Diseases, such as sarcoidosis and Sjogren’s syndrome16, 17 and inflammatory bowel disease18, can affect the eye. Two Web sites to refer to are www.eye.com and www.uveitis.org. Optic neuritis is an inflammation of the optic nerve. It can be caused by multiple sclerosis and by a drug reaction from a medication for tuberculosis. Although it can cause visual loss, it is reversible.19

The eye is a very complex structure, and there are many causes of blurred vision. Blurred vision may be an early manifestation of conditions treatable in primary stages and can indicate serious problems that need attention. In any event, noticing eyesight changes should promote a vigilant patient and their physician to seek immediate attention.

References:

1.   Tomazzoli L, De Natale R, Lupo A, Parolini B. Visual acuity disturbances in chronic renal failure. Ophthalmologica 2000;214(6):403-5.

2.   Basile C, Addabbo G, Montanaro A. Anterior ischemic optic neuropathy and dialysis: role of hypotension and anemia. J Nephrol 2001;14(5):420-3.

3.   Hilz MJ, Marthol H, Neundörfer B. [Syncope - a systematic overview of classification, pathogenesis, diagnosis and management]. Fortschr Neurol Psychiatr 2002;70(2):95-107.

4.   Sinclair SH, Delvecchio C. The internist's role in managing diabetic retinopathy: screening for early detection. Cleve Clin J Med 2004;71(2):151-9.

5.   Miedziak AI, Perski T, Andrews PP, Donoso LA. Stargardt's macular dystrophy--a patient's perspective. Optometry 2000;71(3):165-76.

6.   Terry MA. Dry eye in the elderly. Drugs Aging 2001;18(2):101-7.

7.   Mathews MK, Sergott RC, Savino PJ. Pseudotumor cerebri. Curr Opin Ophthalmol 2003;14(6):364-70.

8.   Binder C, Bendtson I. Endocrine emergencies. Hypoglycaemia. Baillieres Clin Endocrinol Metab 1992;6(1):23-39.

9.   Sarui H, Sano A, Maruyama T, Nakashima K, Takeda N, Yasuda K. Severe graves ophthalmopathy accompanied by HTLV-1-associated uveitis (HAU) and anti-neutrophil cytoplasmic antibody-related vasculitis: a case report and a review of the literature of HAU with Graves disease. Am J Med Sci 2002;324(2):109-14.

10. Suhardjo, Utomo PT, Agni AN. Clinical manifestations of ocular toxoplasmosis in Yogyakarta, Indonesia: a clinical review of 173 cases. Southeast Asian J Trop Med Public Health 2003;34(2):291-7.

11. Marcus N, Hourvitz A. [Botulism disease]. Harefuah 2002;141 Spec No:73-7.

12. Friedberg DN. Cytomegalovirus retinitis: diagnosis and status of systemic therapy. J Acquir Immune Defic Syndr Hum Retrovirol 1997;14 Suppl 1:1-6.

13. Takashima S, Tateishi J, Taguchi Y, et al. [Creutzfeldt-Jakob disease with a widespread presence of kuru-type plaques after cadaveric dural graft replacement. An autopsy case]. Rinsho Shinkeigaku 1997;37(9):824-8.

14. Wadsworth JDF, Asante EA, Desbruslais M, et al. Human prion protein with valine 129 prevents expression of variant CJD phenotype. Science 2004;306(5702):1793-6.

15. Takayama S, Hatsuda N, Matsumura K, Nakasu S, Handa J. [Creutzfeldt-Jakob disease transmitted by cadaveric dural graft: a case report]. No Shinkei Geka 1993;21(2):167-70.

16. Araki T, Katsura H, Motegi T, et al. [Two elderly patients with sarcoidosis and Sjögren's syndrome]. Nippon Ronen Igakkai Zasshi 2001;38(2):229-34.

17. Doi M, Uji Y. A case of uveitis associated with idiopathic retroperitoneal fibrosis. Am J Ophthalmol 1994;117(3):358-62.

18. Mintz R, Feller ER, Bahr RL, Shah SA. Ocular manifestations of inflammatory bowel disease. Inflamm Bowel Dis 2004;10(2):135-9.

19. Fang J-T, Chen Y-C, Chang M-Y. Ethambutol-induced optic neuritis in patients with end stage renal disease on hemodialysis: two case reports and literature review. Ren Fail 2004;26(2):189-93.

Answer provided by Stephen Z. Fadem, MD, FACP, who serves as a member of the AAKP Medical Advisory Board and a Vice President of the AAKP National Board of Directors. Dr. Fadem is a practicing nephrologist in Houston.

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in the March 2005 issue of aakpRENALIFE, Vol. 20, No. 5.

http://www.aakp.org/aakp-library/Dialysis-and-Vision/

[Riki]

for me, night blindness was noticed just before I started dialysis, in the year before.  My kidneys were probably failing at that point, but we didn't know they were failing until I got sick. I actually went into toxic shock.

My eyes were checked and tested many times since then.  I had a cataract removed when I was 23, I have another one maturing.  I"m told that was caused by the steroids I was on after my first transplant.  When I was 15, I took a bad reaction to a mild antibiotic that I was given to prevent UTI. I had every side effect listed on the drug information.  What we didn't know until later, was that the drug caused fluid to build on the optic nerve  When I was 17, I was told that I had retinal degeneration and was declared legally blind.  Since then it was decided that I have something called Bardet-Biedl syndrome, which is a genetic disorder that affects the eyes and the kidneys, but I don't believe it. There are several telltale signs of the syndrome, and I have only2, kidney failure and retinal degeneration.

[Restorer]

Just before I went on dialysis, my phosphorus and creatinine were climbing higher and higher, and it affected my eyesight - specifically, the dilation of my pupils. It took me several minutes for my eyes to adjust to dark places, coming in from daylight, and then it took several minutes to adjust to the bright sunlight when going outside.

Last year, my blood pressure was very high for a couple weeks, and it caused increased intracranial pressure, which cause my optic nerves to swell. That made my eyesight VERY blurry and somewhat sensitive to light. Being driven to the hospital, everything looked like it was immersed in a brightly glowing, dense fog. Fortunately, it went away a couple weeks after my blood pressure came down, but I still have some small lasting effects (fortunately in the eye that was bad to begin with).

[Riki]

I wear sunglasses when I go outside, usualy.  Unless I forget them, like I did today. I ended up having to close my eyes for most of the trip.  Sometimes I fall asleep doing that. *L*

The glasses do help, though.  I don't have to squint.  I was told that amber glasses are the best.

[carson]

I've developed hyperphotosensitivity over the years. I contribute this to the prednisone I've been taking for 28 yrs. I wear sunglasses everywhere I go and have different strengths for different days. It also affects my reading and tolerance on the computer. I've tried using a filter of red or purple and that helps tremendously.