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Posterior ischemic optic neuropathy (PION) presents as a rapidly progressive painless vision loss unilaterally or bilaterally. It can be classified based on the etiology and includes peri-operative PION, risk factors of which include hypotension and anemia. Intradialytic hypotension (IDH), the most frequently encountered complication of hemodialysis, can manifest as perfusion-related symptoms leading to significant morbidity and mortality. However, its possible effects on vision are poorly documented.
We report a case of a 42-year-old female with end-stage renal disease from diabetic nephropathy on maintenance hemodialysis 3x/week for four years with uncontrolled hypertension due to medication non-adherence. She presented with sudden painless, bilateral vision loss during hemodialysis, with no other accompanying symptoms. She was immediately admitted and findings include visual acuity of only hand movement, with fair light projection, good color discrimination, and pale optic nerve. Review of blood pressure (BP) during dialysis ranged from SBP of 120 to 150 mmHg. Workup showed moderate anemia; MRI revealed an acute infarct of the right middle cerebral artery territory, and chronic lacunar infarcts. Antihypertensive medications were adjusted, and hemodialysis was continued with lower ultrafiltrate volume to prevent hypotension. She was given intravenous methylprednisolone pulse therapy at 1g/day and erythropoietin alpha 20,000 units/day for 3 days with minimal visual recovery only until counting fingers at 2 feet after a few days. Eventually, the patient suffered from an acute ischemic stroke and expired from respiratory failure from nosocomial pneumonia.
POIN as a complication of hemodialysis is a rare phenomenon. The BP trends during hemodialysis in addition to uncontrolled hypertension and poor adherence to medications serve as patient’s risk factors for IDH. The ophthalmologic findings were congruent with PION. Relative hypotension, diabetes, and anemia were the identified risk factors for the reported POIN. Current data available suggest that the neuroprotective, angiogenic, and anti-apoptotic effects of erythropoietin can be used for improving visual outcomes in patients with ION, in addition to steroids which addressed the possible resulting inflammation. This report highlighted the occurrence of this phenomenon as related to hemodialysis and that currently, there is still no established treatment for this disease. We emphasize vigilance in patients presenting with these symptoms in terms of blood pressure control and management of anemia and other risk factors as the best treatment is still prevention. Further studies can be done looking into the ophthalmologic findings of patients on chronic hemodialysis which may be correlated with blood pressure, control of diabetes, and degree of anemia.