Sequential nonarteritic anterior ischemic optic neuropathy in patient on chronic hemodialysis

Abstract

Nonarteritic anterior ischemic optic neuropathy (NAION) is a well acknowledged rare complication of chronic hemodialysis in patients with end-stage renal disease (ESRD). We present a unique case of a patient on chronic hemodialysis who presented with an NAION in the right eye, then 3 months later developed an NAION in the left eye followed in 1 month by second NAION episode in the left eye. Every episode of NAION was accompanied by intradialytic hypotension (drop in systolic blood pressure of over 20 mmHg) where visual loss was noticed at the end of the dialysis session. Clinicians should be aware of association between NAION and hemodialysis and that patients with dialysis-induced hypotension are at particularly increased risk of having NAION. Patients who had dialysis-associated NAION should be closely monitored to prevent occurrence of intra-dialytic hypotension as they are at the highest risk of sequential NAION and thus severe visual loss.

A Taiwan Nationwide Population-Based Study of Socio-Demographic Factors and Comorbid Conditions Associated with Non-Arteritic Anterior Ischaemic Optic Neuropathy

“…We found that, compared to the control group, patients with CKD had a significantly higher risk of developing NAION (adjusted OR = 3.26, 95% CI = 2.65–4.01, p < 0.0001). This finding concurred with the results of previous studies [18, 19, 23]. Chang et al analysed 93,804 patients with end-stage renal disease and 93,804 controls and found that end-stage renal disease was an independent risk factor for NAION (adjusted hazard ratio = 2.31, 95% CI = 1.40–3.82) in the total sample cohort [19].…”

“…Finally, patients with hypotension were also found to have significantly higher odds of developing NAION than controls (adjusted OR = 2.32, 95% CI = 1.31-4.10, p = 0.0039). The relationship between NAION and hypotension has been documented in several studies involving nocturnal hypotension [24,25], haemodialysis-related hypotension [18,23], and hypotension after orthopaedic surgery [20][21][22]. Hayreh et al hypothesised that perfusion to the optic disc may be impaired by nocturnal hypotension, leading to NAION, especially in patients with vascular risk factors (particularly hypertension and diabetes) [24,25].…”

“…The pathogenesis of NAION is believed to be multifactorial and mainly results from non-perfusion or hypoperfusion of the optic nerve head, which could be the consequence of a small and crowded optic disc, decreased blood oxygen carrying capacity, low blood delivery, or increased vascular resistance [1-3, 6, 9]. Previous studies have elicited many potential risk factors including the anatomic predisposition of a "crowded" optic disk [10,11], diabetes mellitus (DM) [12][13][14][15][16], hypertension [15][16][17], hyperlipidaemia [14][15][16], chronic kidney disease (CKD) [18,19], and hypotension [18,[20][21][22][23][24][25].…”

An update review of intradialytic hypotension: concept, risk factors, clinical implications and management

“…Similarly, case reports have observed other rare complications of chronic HD occurring immediately after IDH episodes. For example, a patient develops non-arteritic anterior ischaemic optic neuropathy three times in 4 months; each episode was noticed at the end of a dialysis session complicated by IDH [ 60 ].…”

Readers response to “Sequential nonarteritic anterior ischemic optic neuropathy in patient on chronic hemodialysis”

“…It was with exceptional interest that we read Shemesh and Margolin's article published in the last number of the journal [1], where they report the case of a patient with endstage kidney disease (ESKD) on renal replacement therapy who developed a nonarteritic anterior ischemic optic neuropathy (NAION) in both eyes in a sequential manner that the authors associated with Intradialytic Hypotension (IDH) episodes. Nevertheless, we consider that there are certain aspects of their report which deserve to be discussed.…”