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Kidney Week

Abstract: PO0897

Eye Pain During Hemodialysis: Ocular Dialysis Disequilibrium?

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Abdel Massih, Sarah, Virginia Commonwealth University Health System, Richmond, Virginia, United States
  • Aggarwal (Gupta), Monika, VA Richmond Medical Center, Richmond, Virginia, United States

Changes in Intraocular pressure (IOP) during hemodialysis (HD) are underrecognized. We report a case of increased IOP during HD, successfully treated with adjustments to dialysis prescription.

Case Description

39-year-old African American man with End Stage Renal Disease (ESRD) secondary to diabetic nephropathy on HD since 2017, presented with excruciating right eye pain during HD for 2 weeks. He described increasing right eye pain during HD, requiring early termination of dialysis after 3 hours. He has known right eye glaucoma with no vision. He was on atropine sulfate, prednisolone acetate, latanoprost, dorzolamide/timolol, and brimonidine tartrate eye drops. IOP in right eye were 63 and 80 mm of Hg, before and after hemodialysis, respectively. Left eye IOP were < 20 mm of HG and did not change significantly with dialysis. Due to concerns for ocular dialysis disequilibrium; blood flow rate, dialysate flow rate, dialysate temperature, and dialysate sodium were changed to 400 ml/minute from 450 ml/minute, 500 ml/minute from 800 ml/minute, 35.6 C from 37 C, and 145 mEq/L from 140 mEq/L , respectively. Subsequent to changes to dialysis prescription, patient was able to complete dialysis with no worsening of right eye pain and IOP ( 62 and 64 mm of HG before and after dialysis, respectively).


Increase in IOP during HD is thought be due to rapid decline in plasma osmolality relative to aqueous humor, creating an osmotic gradient that causes movement of water into the eye. Patients with normal eye outflow have minimal rise in IOP as aqueous humor is drained simultaneously. However, patients with glaucoma are not able to drain excess water, causing increase in IOP and eye pain.
Older age, diabetes mellitus, and African-American race are risk factors for ESRD and Glaucoma. Early recognition of ocular disequilibrium syndrome can allow for safe delivery of dialysis in patients with glaucoma. While acetazolamide is an effective treatment for raised IOP, it’s efficacy and safety in ESRD remains unknown. Similarly role of Mannitol in mitigation of ocular dialysis disequilibrium is unclear. Our patient had resolution of ocular dialysis disequilibrium with decrease in blood and dialysate flow rates, increase in dialysate sodium, and decrease in dialysate temperature. Increase in ultrafiltration may also reduce risk of ocular dialysis disequilibrium by raising extracellular oncotic pressure.