The aim of this paper was to evaluate the ocular findings in patients with chronic renal failure (CRF) undergoing
haemodialysis (HD). In 64 patients undergoing haemodialysis (30 female and 34 male), aged 24–83 years (mean 58
years) on haemodialysis 1–213 months (mean 47 months) complete ocular examination were performed: visual acuity
(VA), intraocular pressure (IOP), biomicroscopic examination and fundoscopy. On right eye sixty-nine percent of patents
had VA 0.6 or better, and on left eye 84% of patients had VA 0.6 or better. Mean IOP before dialysis was 15 mmHg
and after dialysis was 14 mmHg. In 9 patients (14%) we found corneo-conjunctival calcium deposits. No correlation of
ocular calcification and parathyroid hormone (PTH) level or calcium and phosphate product were observed. 39 (60%)
patients had cataract. Hypertensive vascular changes were seen in 44 (68%) patients and in 6 (7%) patients age-related
macular degeneration. Seven patients had diabetes mellitus and in 5 diabetic retinopathy was observed. Patients with
CRF or who are receiving HD represent unique group of patients. Pathologic change could be found in many tissue and
organs, therefore we suggest ocular examination more frequently in dialysis patients

Antonio Sesar

Draško Pavlović

Kajo Bućan

Krešimir Mandić

Romano Vrabec

Svjetlana Čala

Zoran Vatavuk

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Coll. Antropol. 29 (2005) Suppl. 1: 95–98UDC 617.7:616.61-008.6Original scientific paperOcular Findings in Patients with Chronic RenalFailure undergoing HaemodialysisRomano Vrabec1, Zoran Vatavuk1, Dra{ko Pavlovi}2, Antonio Sesar1, Svjetlana ^ala2,Kre{imir Mandi}3 and Kajo Bu}an41 University Department of Ophthalmology, Clinical Hospital »Systers of Mercy«, Zagreb, Croatia2 Department of Nephrology and Dialysis, Clinical Hospital »Systers of Mercy«, Zagreb, Croatia3 Medical School, University of Zagreb4 University Department of Ophthalmology, University Hospital Split, Split, CroatiaA B S T R A C TThe aim of this paper was to evaluate the ocular findings in patients with chronic renal failure (CRF) undergoinghaemodialysis (HD). In 64 patients undergoing haemodialysis (30 female and 34 male), aged 24–83 years (mean 58years) on haemodialysis 1–213 months (mean 47 months) complete ocular examination were performed: visual acuity(VA), intraocular pressure (IOP), biomicroscopic examination and fundoscopy. On right eye sixty-nine percent of pat-ents had VA 0.6 or better, and on left eye 84% of patients had VA 0.6 or better. Mean IOP before dialysis was 15 mmHgand after dialysis was 14 mmHg. In 9 patients (14%) we found corneo-conjunctival calcium deposits. No correlation ofocular calcification and parathyroid hormone (PTH) level or calcium and phosphate product were observed. 39 (60%)patients had cataract. Hypertensive vascular changes were seen in 44 (68%) patients and in 6 (7%) patients age-relatedmacular degeneration. Seven patients had diabetes mellitus and in 5 diabetic retinopathy was observed. Patients withCRF or who are receiving HD represent unique group of patients. Pathologic change could be found in many tissue andorgans, therefore we suggest ocular examination more frequently in dialysis patients.Key words: chronic renal failure, haemodialysis, ocular findingsIntroductionChronic renal failure (CRF) is an irreversible deteri-oration of renal function. It is characterised by a numer-ous disorders that involve many organs: bone, heart andblood vessels, periferal nerves etc. In dialysis patientssome disorders could be consequence of the dialysistreatment per se. The most common cause of CRF is dia-betic nephropathy, followed by hypertensive nephroan-giosclerosis and various primary and secondary glome-rulonephropaties. Pathologic changes of many organscould be also the consequences of these diseases. One ofthe most important complication of chronic renal failureis disturbance of mineral metabolism, i.e. secondaryhyperparathyroidism. Common feature of mineral me-tabolisam disturbance in CRF is soft tissue calcification.The pathogenesis of this calcification is not completelyunderstood but ocular calcifications are among the mostfrequently observed. The visual sistem could be ad-versely affected not only by pathologic calcification thanalso by by other disturbance in CRF and haemodialysisiper se. Therefore the goal of our study was to evaluatethe ocular changes in chronic haemodialysis patients.Glaucoma is one of most important cause of blind-ness worldwide is impotrant to observe IOP in dialysispatients especialy in patients with glaucoma. Changesin haemoconcentration, plasma colloid-osmotic pressu-re, plasma osmolarity during HD could be registrated. Itis important to reveal their influence on IOP. Posterioreye segment pathology, according to main causes ofCRF, could be hypertensive vascular changes and dia-betic retinopathy1–15.Patients and MethodsIn our study we included 64 patients, 30 females and34 males. Mean age of patients was 58 years (range,24–83 years). Duration of HD ranged from 1 to 213months (mean 47 months). All patients were on haemo-95Received for publication January 11, 2005U:\coll-antropolo\coll-antro-okultni\vrabec.vp28. travanj 2005 15:44:48Plate: 1 of 4Color profile: DisabledBlack  150 lpi at 45 degreesdialysis 3 times a week, 4 hours; bicarbonate dialysatewas used with 1.5 mmol/l Ca concentration. Most of thepatients were on calcitriol therapy (up to 0.5 g per day)and calcium carbonate was used as phosphate binder(up to 4 g per day). Heparin was used during haemo-dialysis in all patients in a dose up to 4000 i.u. In all pa-tients we performed ocular examination which includevisual acuity (VA), intraocular pressure (IOP), biomicro-scopic examination, fundoscopy. Visual acuity was as-sessed with Snellen chart. We measured IOP usingGoldmann aplanation tonometry half an hour beforeand half an hour after HD treatment. On slit lamp weexamined corneal and conjuctival calcium deposits. Weused Porter and Crombie¹ method for gradation of cal-cium deposits. Transparency of lens was observed on slitlamp and classified according to the lens opacities clas-sification system III (LOCS III)16 For ocular backgroundwe used direct and indirect fundoscopy and fundus pho-tography. Intact parathyroid hormone (PTH) level (nor-mal range 1–64 g/l), and calcium (Ca) (normal range2.25–2.6 mmol/L) phosphorus (P) (normal range 0.64–1.35 mmol/L) level were detected and and calcium andphosphorus product calculated. The aim was to find cor-relation between the amount of calcium deposits on cor-nea and conjunctiva and serum levels of PTH, Ca, P, andCa x P product.ResultsSixty-nine percent of patients had visual acuity 0.6or better on right eye. On left eye 84% patients had VA0.6 or better. In our group we did not have patients withglaucoma. IOP before treatment ranged 11–20 mmHg(mean 15 mmHg) and 11–20 mmHg (mean 14 mmHg)after the treatment so we did not find significant chan-ges IOP during HD, but we had mild decrease in IOP(Table 1). One patient (F) developed acute elevation ofIOP on left eye, 41 mmHg 7 months after beginning ofHD.In 9 (14%) patients we found corneo-conjuctival de-posits. They were mostly located in superficial subepi-thelial part of corneal limbal area as well in paralimbalnasal and temporal part of conjunctiva in horizontal me-ridian from 9 to 3 o´clock According to Porter andCrombie classification they were mostly mild to moder-ate (Table 2). We did not find significant corneal edema.Central parts of the cornea was clear. In five patientswith calcium deposits we also found higher value of se-rum PTH. Sixteen patients had higher values of serumPTH but without calcium deposits (Table 3).When we calculated the product of serum calciumand phosphorus, we found that forty-five patients hadhigh level of Ca x P but no deposits. Nine patients hadcorneo-conjuctival calcium deposits and high level in Cax P (Table 4). We did not find statistically significantcorrelation between calcium deposits and level of PTH,nor calcium deposits and value of Ca x P using Kruskal-Wallis test.Thirty-nine patients had cataracts. In twenty-ninepatients (45%) we found initial form and in 10 (15%) pa-tients we found advance form of cataracts according toLOCS III classification (Table 5). On posterior eye seg-ment we found hypertensive vascular changes in 44(68%) patients. Most patients had mild to moderate hy-pertensive vascular changes. Six patients had advancedvascular sclerosis (Table 6). At the Department for hae-modialysis were 7 patients with diabetes mellitus whichis also a important cause for HD. We found nonproliphe-rative diabetic retinopathy in 4 (6%) patients, proliphe-rative diabetic retinopathy in 1 (1.5) patients. Three(4%) patients were treated by argon laser photocoagu-lation (Table 7). In 6 (7%) patients we found aged-re-lated macular degeneration (ARMD).R. Vrabec et al.: Ocular Changes in Haemodialysis Patients, Coll. Antropol. 29 (2005) Suppl. 1: 95–9896TABLE 1IOP BEFORE AND AFTER DIALYSISBefore dialysis After dialysisRange 11–20 mmHg 11–20 mmHgMean 15 mmHg 14 mmHgTABLE 2GRADING CALCIUM DEPOSITS (GRADE 0–5)Grade 0 1 2 3 4 5Patients 55 3 2 3 1 0TABLE 3CALCIUM DEPOSITS AND VALUE OF PTHCa deposits Total MV SDWith 5 342.6 278.0Without 16 342.7 327.0TABLE 4CALCIUM DEPOSITS AND VALUE OF CA x PCa deposits Total MV SDwith 9 4.3 0.9without 45 3.8 1.1TABLE 5CATARACT (LOCS III)<NC2C2 >NC2C229 (45%) 10 (15%)TABLE 6HYPERTENSIVE VASCULAR CHANGES SCHEII II III IV18 (28%) 20 (31%) 5 (7%) 1 (1%)U:\coll-antropolo\coll-antro-okultni\vrabec.vp28. travanj 2005 15:44:49Plate: 2 of 4Color profile: DisabledBlack  150 lpi at 45 degreesDiscussionPatients with end stage renal disease (ESRD) under-going haemodialysis represent specific group of patientswho have more than one disease and therefore should becarefully examined. About 80% of patients had visualacuity 0.6 and better. In our study we had two patientswho were blind to one eye due to traumatic injury. Softtissue calcifications are often seen in CRF patients,moreover due to increasing age and longevity of haemo-dialysis and better sophisticated diagnostic techniques,pathologic extraskeletal calcifications could be find inevery haemodialysis patients. The pathogenesis is notcompletely understood. It was thought that it representdystrophic, passive calcification due to physical-chemi-cal processes. But today we know that is is also a regu-lated process modulated by various genes and proteins,i.e. osteocalcin, osteoponitn etc. Ocular calcifications(corneal nad conjunctival) are the most comon meta-static calcification in patients with CRF and on HD. Pa-tients with corneal calcifications could complain of agritty sensation and in patients with conjuctival calcifi-cations acute injction and inflammation of conjuctiva(»red eye syndrome) could be find. Calcium depositsmainly consist calcium phosphat salts. There are somespecific reasons in pathogenesis of ocular calcificationsis not fully understood. Some authors suggests that cal-cium deposits are more likely to perciptate at corneaand conjuctiva due to loss of CO2 from that tissue withrise in pH which is ideal for precipitation of calciumphosphat salts in the presence of high values of serumcalcium phosphat.1,2 It is also possible that some kind ofcorneal degeneration or minor corneal and conjuctivaltrauma have significant role in deposit formation. Vu-nerability can be result of decrease of tear secretion dur-ing each haemodialysis treatment5–8. We find 9 patientswith corneo-conjuctival deposits which are grade 1–4and duration of HD in this patients were between 2–12years (mean 7 years). No correlation of PTH level or Cax P product level were found. It is in agreement withwell known fact that pathologic calcifications is not onlydue to increased level of calcium and phosphorus (i. e.passive process). It is active process yet not completlyunderstood.In our study we found no significant implication onvisual acuity in patients with corneo-conjuctival depos-its because the deposits were mild to moderate. De-posits are placed in limbal area and only in later canhave implication on visual acuity. In three patients whocomplained of itching we revealed minute corneal andconjunctival erosions after staining with fluoresceindye. There were no significant changes in IOP, only withslight decrease in IOP during HD. One patient, 74 yearold woman, has developed acute rise in IOP after 7months on dialysis and she was admitted to our clinic.Before that elevation we measured IOP three times onour clinic during 7 months and values were between11–13 mmHg for both eyes. She received medical ther-apy for month and IOP values were between 9–15mmHg. After that she was without therapy with valuesof IOP between 11–16 mmHg. Exact mechanism ofchanges of IOP during HD is not fully understood, so weassumed that elevation of IOP during haemodialysis ismultifactoriel11–13,15. Patients with lower values of IOPcould develop acute elevation in IOP. Some studies dem-onstrated decrease in IOP during HD. Changes in plas-ma colloid-osmotic pressure could be responsible forintradialytic decrease in IOP. Colloid-osmotic pressureis higher during HD due to decrease in plasma volumeowning to removal of water from plasma. To correct thisimbalance water from interstitial spaces and also aque-ous humor move to plasma. So we had decrease inIOP14. Important role as well is production and outflowof aqueous humor. In eyes with impair aqueous outflowand shallow anterior chamber we could observe increasein IOP. For intradialytic increase in IOP could be re-sponsible post dialitytic urea rebound (PDUR)17. Find-ings on ocular background are correspondent with maincause for HD. Forty-four patients have hypertensivevascular changes. Seven patients have diabetes and allhave diabetic retinopathy. ARMD we found in 6 patientsand they are from older group of patients. Ocular back-ground examination is very important in these patientsbecause we can reveal early changes on retinal vesselswhich can also helps in systemic evaluation of disease,efficiency of treatment, compliance with medication andprogression of disease18–21.In conclusion, we suggest ocular examination for allpatients with CRF especially before starting with HDtreatment. It is necessary to prevent any ocular pathol-ogy in dialytic patients because every deterioration invisual system can have great implication in everydaylife and social ability of dialytic patients. Patients un-dergoing HD are very complex we suggest multidisci-plinary approach to patients on haemodialysisR. Vrabec et al.: Ocular Changes in Haemodialysis Patients, Coll. Antropol. 29 (2005) Suppl. 1: 95–9897TABLE 7DIABETIC RETINOPATHYDiabetes 7 (10%)Nonprolipherative diabetic retinopathy 4 (6%)Prolipherative diabetic retinopathy 1 (1.5%)Argon laser photocoagulation 3 (3%)R E F E R E N C E S1. PORTER, R., A. CROMBIE, Br. J. Ophtalmol., 57 (1973) 339. — 2.DUKE ELDER, S., Kimpton., 8 (1976) 132. — 3. MICHAEL, M., D.GARCIA, Nephrol. Nurs. J., 31 (2004) 185. — 4. DURSUM, D., B. DE-MIRHAN, Br. J. Ophtalmol., 84 (2000) 1225. — 5. KLASSEN– BROE-KEMA, N., O. P. van BIJSTERVELD, Br. J. Ophthalmol., 77 (1993) 569.— 6. KLASSEN–BROEKEMA, N., O. P. van BIJSTERVELD, Eur. J.U:\coll-antropolo\coll-antro-okultni\vrabec.vp28. travanj 2005 15:44:49Plate: 3 of 4Color profile: DisabledBlack  150 lpi at 45 degreesR. VrabecUniversity Department of Ophthalmology, Clinical Hospital »Systers of Mercy«, Vinogradska cesta 29, 10000 Zagreb,Croatiae-mail: romanovrabec@hotmail.comO^NE PROMJENE KOD BOLESNIKA S KRONI^NIM ZATAJENJEM BUBREGA NA HEMODIJALIZIS A @ E T A KCilj ovoga rada je evaluacija o~nih promjena kod bolesnika s kroni~nim zatajenjem bubrega na hemodijalizi. Kod64 bolesnika (30 `ena i 34 mu{karca) s kroni~nim zatajenjem bubrega u~injen je o~ni pregled: vidna o{trina, intra-okularni tlak (IOT), biomikroskopski pregled, fundoskopija. Vidna o{trina na desno oko kod 69% bolesnika je bila 0.6i bolja, dok na lijevo oko 84% bolesnika imalo vidnu o{trinu 0.6 i bolju. Srednja vrijednost pola sata prije dijalize bilaje 15 mmHg, a pola sata nakon dijalize 14 mmHg. Kod 9 (14%) bolesnika na{li smo korneo-konjuktivalne depozite.Nije na|ena povezanost izme|u prisutnosti kalcifikata na ro`nici i spojnici te vrijednosti paratiroidnog hormona(PTH) i umno{ka vrijednosti kalcija i fosfora. Kod 60% bolenika na|ena je katarakta. Na o~noj pozadini na|ene su u44 bolesnika hipertenzivne promjene i u 6 bolesnika senilna makularna degeneracija. Sedam bolesnika je imalo dija-betes, a kod 5 je na|ena dijabeti~ka retinopatija. Bolesnici s kroni~nim zatajenjem bubrega na hemodijalizi ~ineposebnu skupinu bolesnika. Patolo{ke promjene nalazimo na mnogim tkivima i organima, stoga savjetujemo o~nipregled kod dijaliti~nih bolesnika u kra}im vremenskim razmacima.R. Vrabec et al.: Ocular Changes in Haemodialysis Patients, Coll. Antropol. 29 (2005) Suppl. 1: 95–9898Ophtalmol., 5 (1995) 7. — 7. KLASSEN–BROEKEMA, N., O. P. van BIJ-STERVELD, Graefes Arch. Clin. Exp. Ophtalmol., 233 (1995) 717. — 8.TOKUYAMA, T., T. IKEDA, K. SATO, O. MIMURA, A. MORITA, T. TA-BATA, Am. J. Kidney Dis., 39 (2002) 291. — 9. DIAZ-COUCHOUD, P., F.D. BORDAS, J. R. F. GARCIA, E. M. CHAMPS, A. CARCELLAR, Cor-nea, 20 (2001) 695. — 10. TAWARA, A., H. K. OBATA, K. FUJISAWA, T.ABE, Y. ONISHI, Curr. 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Dial.Transpant., 8 (1993) 882. — 22. PAVLOVI], D., Acta Med. Croat., 57(2003) 77.U:\coll-antropolo\coll-antro-okultni\vrabec.vp28. travanj 2005 15:44:50Plate: 4 of 4Color profile: DisabledBlack  150 lpi at 45 degrees

Ocular Findings in Patients with Chronic Renal Failure undergoing Haemodialysis

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