Oculars Pain and Intraocular Hypertension in Hemodialysis Patient with Glaucoma: A Case Report and Review of the Literatures

Resistance hypertension in hemodialysis patient usually is common and sometimes diﬃ cult to get achieved target blood pressure control. In patient with intradialytic hypertension, eye pain may occur which can be relate to the severity of the hypertension itself. Hemodialysis has relationship to Intraocular Pressure (IOP). Hemodialysis was be Increased Intraoccular Pressure (IOP) and may be the cause of eye pain during hemodialysis due to ocular dialysis disequilibrium. And this receives inadequate attention by nephrologist as a cause of intradialytic hypertension. In this article, we report a patient with resistant hypertension who complain of right eye pain during and after dialysis. After anterior chamber tapping and the aqueous humor was drained. The symptoms and hypertension improved. Undetected signiﬁ cant increase in IOP during hemodialysis may lead to permanent optic nerve damage and should be recognized as a cause of hypertension. An interesting point of this report was the intraocular hypertension get worsed in hemodialysis patients and could be a cause of resistance hypertension. We suggest regular ophthalmologic evaluation in ESKD (End Stage Kidney Disease) patients should be necessary especially in the patient with poorly controlled hypertension, have previous glaucoma, diabetic retinopathy, eye pain, blurred vision, conjunctivitis and headache.


Introduction
Eye pain during Hemodialysis (HD) is a rare presentation and often goes unfocused in clinical practice. The relationship between Intraocular Pressure (IOP) and hemodialysis was irst documented in 1964 by Sitprija, et al. [1]. The reported evidences of IOP during hemodialysis have different variations. According to review of literature, some publications concluded an IOP increase during or after hemodialysis, while other reports showed a decrease in IOP during hemodialysis or no change. Proposed theories for explanation of IOP changes during HD are a rapid decrease in plasma osmolality and relative increase in the concentration of urea in the aqueous humor [2]. The main mechanism is the extracellular luid shift from the blood compartment to anterior chamber. This osmotic shift during hemodialysis was propose as a new terminology "ocular dialysis disequilibrium" by Cassiopia L, et al. [3] Figure 1. Mechanism of ocular dialysis disequilibrium. The two signi icant risk factors of increased https://doi.org/10.29328/journal.jcn.1001111 IOP during hemodialysis were reported in a meta-analysis 2021 (53 studies, N 1903), including acetate dialysate use and preexisting glaucoma or impaired aqueous humor out low tract [4]. An increase in systolic blood pressure, rapid decrease in serum Na, blood urea nitrogen (BUN) and serum osmolarity have been associated with increased IOP. We reported the resistant severe hypertensive patient, presented with right eye pain during and after dialysis. The interesting point of our case show the unrecognized cause of severe hypertension in regular hemodialysis patient was the progression of glaucoma. Elevation of IOP and reduction of ocular perfusion pressure are the main risk factors for progression of glaucoma. Undetected signi icant increase in IOP during hemodialysis could lead to permanent optic nerve damage and unknown cause of hypertension.

Case report
A 51-year-old male with end stage renal disease due to diabetic nephropathy recieving regular hemodialysis in Sep 2021 has T2DM with severe non proliferative diabetic retinopathy, hypertension and dyslipidemia, dialysis vintage for 10 months. He was prescribed 3 session/week of dialysis via left AVF (arteriovenous istula), duration 4 hour per session.
He was diagnosed with ghost cell glaucoma at right eye in Mar 2021 due to blurred vision and right eye pain with baseline vision acuity 20/125, 20/100 and Intraocular Pressure (IOP) was measured by icare Tonometer probe (TP01) reaching 14 and 12 mmHg in the right and left eyes, respectively. At the onset of irst diagnosis of glaucoma, his IOP increased to 23,18 mmHg. The ophthalmologist prescribed topical therapy (Carbonic anhydrase inhibitor, 1% Prednisolone, alpha 2 adrenergic receptor agonist and Prostanoid selective prostaglandin F receptor agonist. After treatment, the patient was relieved from pain there was a decrease in IOP to 14,12 mmHg. Two months ago he developed recurrent right eye pain at an intradialytic session. He complained of right eye pain (pain score 8/10) and throbbing headache located at right temporal area in the 2 nd hour after starting hemodialysis and peak symptoms were established at after dialysis. The patients developed uncontrolled hypertension during the use of Furosemide 1000 mg, Manidipine 20 mg, Losartan 100 mg and Bisoprolol 10 mg per day. The pain symptoms completely recovered at 1 -2 days after dialysis and were recurrent in the next session of dialysis period. On presentation the IOP was 55 and 22 mmHg (normal< 20 mmHg) in right and left eye. His regular dialysis prescription normally takes 4 hours with blood low rate 300 ml/min, dialysate low rate 500 ml/min, temperature 36.5 °C, 2.5 L luid removal, dialysate Na 138 mmol/L, K 2 mmol/L, Ca 2.5 mEq/L, HCO 3 -34 mEq/L. His predialysis blood pressure were 180 -211/90 -94 mmHg in clinical setting with no signs of volume overload and dry weight was kept at 70 Kg. In this case we adjusted dry weight by blood volume monitoring. This patient had severe eye pain during dialysis and his IOP increased from 55, 22 mmHg (predialysis) to 60, 26 mmHg (2 nd hr) and 70, 26 mmHg (post dialysis) in right and left eye (Table 1).

Lab investigation at the onset of severe eye pain during hemodialysis
CBC: Hb 9.7 HCt 31%, WBC 5600/cumm, N 71%, L 21%, Platelet 134,000/cumm, BUN 99 mg/dL, Cr 11 mg/dL, After anterior chamber tapping, the eye pain recovery and his IOP decreased with a dramatic response to normal level in 5 days and pre dialysis blood pressure decreased to 150/70 mmHg in a few weeks.

Discussion
Intraocular pressure change during HD was investigated by worldwide several study. However, the results were varied from decrease, unchanged and increase IOP. Because there have confounding effects such as IOP measurement, patient position during dialysis, history of glaucoma and aqueous out low tract facility. According to Vachirasakchai V. study, 41 patients with ESRD on HD ware mesured IOP during dialysis in regular supine position. IOP was found to be increased both during HD (2 hours) and signi icant increased after HD [5][6][7][8][9][10][11][12][13][14][15][16][17].
Resistant hypertension is common problem in ESRD. We appreciate to show the case that had a cause of uncontrolled hypertension from eye pain. Undetected signi icant increase in IOP during hemodialysis can develop without symptoms and it can aggravate eye pain, ciliary injection, blurred vision or headache. The IOP during hemodialysis according to the studies demonstrated the interindividual variability. Interestingly, previous glaucoma and anatomical defect of aqueous humor out low tract at iridocorneal angle are the main risk factors for increase in IOP during hemodialysis while, in normal the aqueous humor drainage via the canal of Schlemm to the lymphatic drainage can occur. In this this case the patient had regular dialysis and the pain in the eyes is not caused from dialysis disequilibrium, but from the underlying progressive glaucoma which aggravated the symptoms, severe hypertension, and increase in IOP. The pain recovery and blood pressure were controlled after correcting the speci ic cause of disease by anterior chamber tapping.
Our management approach of ocular dialysis disequilibrium showed in Figure 2. Dialysis Na should be increase for control tonicity of plasma osmolarity. Decrease blood low rate and dialysate low rate for slow urea removal and adjust ultra iltration rate for control dry weight. Second line treatment was mannitol or hypertonic saline solution intravenous infusion could decrease IOP. In cases failure of medical treatment, shift mode of dialysis to peritoneal dialysis should be consider.

Conclusion
An Increase IOP associated with hemodialysis especially in cases have glaucoma, impaired aqueous humor out low tract. Eye pain during hemodialysis could be a cause of uncontrolled hypertension. An attention to regular ophthalmologic assessment in dialysis patients should be done especially in the patients with risk factors, such as diabetic retinopathy, poorly controlled hypertension, and previous eye diseases.

Acknowledgement
I would like to thank all the staff and hemodialysis nurse of Nephrology Division at Phramongkutklao Hospital

Disclosure statement
None of the authors have any professional relationships with companies or manufacturers that would bene it from the results of the present study.

Funding
A part of the present study was supported by Biomedical Research and Development Center, Phramongkutklao Hospital.