Eye Pain During Hemodialysis in Severe Proliferative Diabetic Retinopathy With Neovascular Glaucoma

Abstract

Purpose: To report a case of severe eye pain developing during dialysis. Methods: A case report was performed. Results: A 41-year-old man with uncontrolled type 2 diabetes and end-stage nephropathy developed severe pain in the left eye during hemodialysis. A decline in vision in both eyes was reported over the preceding year, with blindness in the left eye for 6 months. The best-corrected visual acuity was 20/150 OD and light perception OS. The intraocular pressure was 14 mm Hg and 59 mm Hg, respectively. An examination found disc neovascularization with a “volcanic eruption” of vitreous hemorrhage from the optic nerve in the right eye and significant corneal edema and iris neovascularization with no posterior view in the left eye. The patient required urgent cyclophotocoagulation for neovascular glaucoma (NVG) in the left eye, bilateral antivascular endothelial growth factor injections, and panretinal photocoagulation in the right eye for proliferative diabetic retinopathy. Conclusions: Worsening eye pain during hemodialysis in a patient with NVG indicates severely limited outflow capacity and requires immediate intervention.

Introduction

Neovascular glaucoma (NVG) is characterized by proliferation of fibrovascular tissue in the anterior chamber angle secondary to retinal ischemia. Diabetic retinopathy (DR) and central retinal vein occlusion are the most common etiologies. ¹ Because these neovascular blood vessels extend across the scleral spur, they can obstruct the trabecular meshwork and compromise aqueous outflow, raising intraocular pressure (IOP). The prevalence of NVG in patients with diabetes is 2%, increasing to 21% in patients with proliferative DR (PDR). ² The visual prognosis is guarded given the optic nerve damage and complications from the underlying retinal vascular disease. Close follow-up with IOP control and management of the underlying condition are crucial for preventing irreversible vision loss. ³

We report a case of a young patient with uncontrolled diabetes who was lost to follow-up until he developed severe eye pain during hemodialysis secondary to PDR complicated by NVG.

Case Report

A 41-year-old man with uncontrolled type 2 diabetes and end-stage nephropathy was urgently referred to the county safety-net clinic for progressively severe episodes of pain in the left eye during hemodialysis for 1 month. He reported a progressive decline in vision in both eyes over the preceding year, with blindness in the left eye for 6 months. The patient had been lost to follow-up in our clinic for the previous 2 years. At his last clinic visit, antivascular endothelial growth factor (anti-VEGF) injections were recommended in both eyes for diabetic macular edema. However, because of a strong fear of needles, the patient did not return.

The best-corrected visual acuity was 20/150 OD and light perception OS. The IOP was 14 mm Hg and 59 mm Hg, respectively. An examination showed disc neovascularization with a “volcanic eruption” of vitreous hemorrhage emanating from the optic nerve in the right eye (Figure 1, A–C) and significant corneal edema and iris neovascularization in the left eye with no posterior view. The presence of vitreous hemorrhage in the right eye and NVG in the left eye were the result of chronic, poorly controlled PDR exacerbated by nonadherence to follow-up and treatment. The patient required urgent cyclophotocoagulation for NVG in the left eye, bilateral anti-VEGF injections, and panretinal photocoagulation in the right eye for PDR.

Figure 1.

Neovascularization of the disc with a “volcanic eruption” of vitreous hemorrhage on fundus photography (A), ultra-widefield pseudocolor imaging (B), and midphase ultra-widefield fluorescein angiography (C) in the right eye. Also seen are cotton-wool spots, microaneurysms, and extensive capillary nonperfusion.

Conclusions

The effects of dialysis on IOP were first noted in 1964. ⁴ Since then, studies have documented increases and decreases in IOP as well as the stability of IOP during hemodialysis. ⁵ The removal of solutes during the process may reduce serum osmolality faster than ocular osmolality and favors the movement of aqueous into the anterior chamber. In patients with significant outflow obstruction, these fluid shifts cannot be accommodated and result in episodic elevations in IOP. Worsening eye pain during hemodialysis in a patient with NVG may indicate severely limited outflow capacity and requires immediate intervention.

In addition, hemodialysis might exacerbate vitreous hemorrhage as a result of the effects of systemic anticoagulation. ⁶ Although the vitreous hemorrhage typically resolves, it may require surgical intervention in persistent cases. Continued treatment of the underlying DR and diabetes control are essential to prevent further vision loss. Last, loss to follow-up is prevalent among low-income and minority patient populations who rely on safety-net clinics for care.^7,8 Interventions to increase the adherence to treatment may continue to improve visual outcomes.