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Kidney Week

Abstract: PO0900

Posterior Ischemic Optic Neuropathy After Hemodialysis In a Patient with Uncontrolled Diabetes Mellitus

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Abo-Zed, Abdelrhman, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Paez-Escamilla, Manuel A., University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Kalaria, Arjun Lalit, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Abramovitz, Blaise William, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Waxman, Evan L., University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
Introduction

Posterior ischemic optic neuropathy (PION) results from ischemic damage to the retrobulbar optic nerve and presents as severe acute painless unilateral or bilateral loss of vision. Any procedure that results in sufficient optic nerve hypoperfusion can cause retrobulbar optic nerve damage. Hemodialysis (HD) as a cause of peri-procedural bilateral PION is a rare complication. While there are reports of successful cases of treatment with hyperbaric oxygen treatment and steroids, there is no established treatment protocol and the prognosis for recovery of vision in patients with peri-procedural PION is poor.

Case Description

A 34-year-old male with end-stage renal disease on HD presented with respiratory complaints and hypertensive emergency (BP 224/135 mmHg). His past ocular history was significant for proliferative diabetic retinopathy. Due to volume overload, he underwent emergent HDovernight with ultrafiltration of 3 L. He underwent a subsequent HD treatment with additional ultrafiltration of 3 L the following morning with lowest BP 117/73 mmHg. Shortly after the second HD treatment, he complained of bilateral painless complete loss of vision. He was found to have no light perception in either eye. Pupils were 3 mm and amaurotic. A dilated fundus exam showed perfused-appearing optic nerves. A presumptive diagnosis of bilateral PION was made due to relative hypotension during HD. The patient was treated with erythropoietin (EPO) 10,000 units twice daily and IV methylprednisolone for 3 days according to the protocol suggested by Nikkah et al for non-arteritic anterior ischemic optic neuropathy. Examination 14 hours after the first dose showed marked clinical improvement and he regained his vision. The patient underwent two more HD sessions with careful attention paid to avoiding hypotension. He had no subsequent vision loss. When he was seen in the eye clinic 4 days after discharge, his visual acuity remained stable.

Discussion

EPO has been proposed as a treatment agent for ischemic optic neuropathy. Bilateral loss of light perception is a rare complication related to hypotension on HD. The presumed etiology in this case was PION. Prompt treatment with EPO and intravenous steroids should be considered in similar situations that result in PION related to procedure-based hypotension.