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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 27  |  Issue : 6  |  Page : 1252-1255
Renal fluid overload diagnosed by retinal optical coherence tomography scanning


1 Department of Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
2 Department of Nephrology, Veterans Affairs Medical Center; Department of Medicine, College of Medicine, University of Central Florida, Orlando, FL, USA
3 Department of Medicine, St. Matthew's University, Grand Cayman, Cayman Islands, USA
4 Department of Nephrology, Veterans Affairs Medical Center; Department of Medicine, College of Medicine, University of Central Florida, Orlando, FL; Department of Ophthalmology, Howard University College of Medicine, Washington, DC; Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX; Department of Ophthalmology, University of South Florida College of Medicine, Tampa; Department of Ophthalmology, Florida State University College of Medicine, Tallahassee, FL, USA
5 Department of Medicine, Lake Erie College of Osteopathic Medicine, Bradenton; Department of Nephrology, Veterans Affairs Medical Center, Orlando, FL; Department of Ophthalmology, Howard University College of Medicine, Washington, DC, USA

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Date of Web Publication28-Nov-2016
 

   Abstract 

Fluid overload is one of the major findings in patients with end-stage renal disease. Common findings in fluid overload include shortness of breath, pedal edema, ascites, and pericardial effusion. Rarely, vision loss can be associated with decompensated systemic fluid status. In the following case, we report an unusual case of vision loss due to retinal edema as a result of fluid overload diagnosed and followed to resolution by optical coherence tomography testing.

How to cite this article:
Kar SM, Nguyen TG, Rathod S, Shaikh S, Kar PM. Renal fluid overload diagnosed by retinal optical coherence tomography scanning. Saudi J Kidney Dis Transpl 2016;27:1252-5

How to cite this URL:
Kar SM, Nguyen TG, Rathod S, Shaikh S, Kar PM. Renal fluid overload diagnosed by retinal optical coherence tomography scanning. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Sep 22];27:1252-5. Available from: http://www.sjkdt.org/text.asp?2016/27/6/1252/194682

   Introduction Top


End-stage renal disease (ESRD) patients are at a risk of developing a myriad of eye complications ranging from simple irritation and conjunctival erythema to serious conditions such as optic neuropathy, retinal hemorrhages, and elevated intraocular pressure. We report an unusual case of vision loss as a result of fluid overload secondary to ESRD. For a detailed nephrologist, it is challenging to perform a ophthalmoscopy examination in the dialysis facility. An optic coherence tomography (OCT) becomes an important diagnostic tool allowing in vivo, real-time, high-resolution, cross-sectional images to detect and diagnose conditions generally undetectable by clinical examination.


   Case Report Top


This is a case of a 78-year-old Hispanic male with a long-standing history of diabetes mellitus and hypertension (HTN) which led to ESRD. His past medical history was also significant for atrial fibrillation, congestive heart failure, cardiomyopathy, and gout. He had been receiving hemodialysis three times a week for 180 min, each session for the past four years with dialysate sodium set at 138 mEq/L. He was non-compliant with his dietary and fluid intake gaining 2.2-2.6 kg during intradialytic periods with significant pedal edema. He also demonstrated a poor ejection fraction of 23% on his most recent echocardiogram. The patient has had hypotensive episodes during dialysis, and he has been unable to maintain his ideal "dry weight."

The patient presented to the eye clinic with a four-day history of blurred vision in his right eye noted in the morning following his most recent dialysis session. On examination, his vision was found to be 20/40 in the right eye and 20/20 in the left eye. Color vision testing was normal in both eyes. Fundoscopic examination of both eyes revealed pigmentary changes without obvious evidence of retinal detachment [Figure 1]a and b. OCT scans were performed through the retina which demonstrated shallow subretinal fluid in the macula of both eyes consistent with serous retinal detachments [Figure 2]a and b.
Figure 1: Fundus photographs of the right (a) and left (b) eyes demonstrating foveal pigmentary changes but an otherwise normal appearing fundus.

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Figure 2: Horizontal section optical coherence tomography scan through the center of the right (a) and left (b) maculae demonstrates a serous retinal detachment. A small layer of subretinal fluid is present between the photoreceptors (white arrow) and retinal pigment epithelium (black arrow). N: Nasal, T: Temporal, I: Inferior refer to orientation of scan on maculae.

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The patient was aggressively dialyzed for one week with three isolated ultra-filtration on his nondialysis days and strict fluid intake. Thereafter, the patient was placed on a new dialysis regimen with a dry weight down from 76.5 kg to 71.5 kg. Two months later, the patient noted complete resolution of symptoms and his vision had improved to 20/25 in the right eye and 20/20 in the left eye. OCT scans confirmed the resolution of the subretinal fluid and serous retinal detachment in both eyes [Figure 3]a and b. A repeat echocardiogram was not performed.
Figure 3: Two months follow-up. Horizontal section optical coherence tomography scan through the center of the right (a) and left (b) macula demonstrates normalization of retinal contour with resorption of subretinal fluid. N: Nasal, T: Temporal, I: Inferior refer to orientation of scan on macula.

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   Discussion Top


Retinal detachment occurs when a separation between the retinal pigment epithelium and the neurosensory retina develops. In a serous retinal detachment, fluid accumulates in the subretinal space, the causes of which include idiopathic, inflammatory, malignant, ischemic, and retinal vascular disease. [1] Serous detachments have been reported in systemic conditions that affect the kidneys including systemic lupus erythematosus, Alport's syndrome, and hemodialysis. [2],[3] Reversible serous detachments have been reported in patients with renal failure and concomitant HTN. [4],[5],[6] Serous detachments have also been reported postrenal transplantation, with the hypothesis that neurosensory detachment was due to alterations in extracellular fluid distribution and renal function. [7],[8]

OCT has become one of the most important diagnostic tools in ophthalmology in the last two decades. It allows in vivo, real-time, highresolution, cross-sectional imaging of the retina, the nerve fiber layer, and the optic nerve. It is based on the technique of low coherence interferometry, where a near-infrared light beam is aimed at the medium with the resulting backscattered light generating an image. OCT has allowed for detection and diagnosis of conditions that are undetectable by clinical examination, such as the detection of shallow retinal detachments. [9]

Interdialytic weight gain is associated with renal replacement therapy and it is more prevalent in patients with cardiac and hemodynamic comorbidities. Multiple hospitalizations for the treatment of congested heart failure and pulmonary edema are not uncommon. Dialysis-associated ascites is another common problem associated with fluid indiscretions.

Although vision changes have been reported in renal failure patients, this is, to our knowledge, the first case where OCT scanning directly resulted in a patient's diagnosis. In light of the fluid overload status, a change in the dialysis regimen with more aggressive fluid removal was instituted. The nephrology community should be aware of ophthalmic problems associated with fluid overload and the role of OCT testing as an adjunct modality in documenting fluid overload status.

Conflict of interest: None declared.

 
   References Top

1.
Spaide RF, Goldbaum M, Wong DW, Tang KC, Iida T. Serous detachment of the retina. Retina 2003;23:820-46.  Back to cited text no. 1
    
2.
Yasuzumi K, Futagami S, Kiyosawa M, Mochizuki M. Bilateral serous retinal detachment associated with Alport's syndrome. Ophthalmologica 2000;214:301-4.  Back to cited text no. 2
    
3.
Kamdar NV, Erko A, Ehrlich JS, Kim JW, Kambham N, Chertow GM. Choroidopathy and kidney disease: A case report and review of the literature. Cases J 2009;2:7425.  Back to cited text no. 3
    
4.
Steiness I. Reversible retinal detachment in renal insufficiency. Report of five cases. Acta Med Scand 1968;183:225-9.  Back to cited text no. 4
    
5.
Sharpstone P, Lee HA. Retinal detachment with spontaneous regression in renal failure. Br Med J 1966;2:92-3.  Back to cited text no. 5
    
6.
Lapco L, Weller JM, Greene JA Jr. Spontaneously reversible retinal detachment occurring during renal insufficiency. Ann Intern Med 1965;63:760-6.  Back to cited text no. 6
    
7.
Friberg TR, Eller AW. Serous retinal detachment resembling central serous chorioretinopathy following organ transplantation. Graefes Arch Clin Exp Ophthalmol 1990;228:305-9.  Back to cited text no. 7
    
8.
Scorolli L, Giardina D, Morara M, Corazza D, Meduri RA. Bilateral serous retinal detachments following organ transplantation. Retina 2003;23:785-91.  Back to cited text no. 8
    
9.
Wang M, Sander B, Lund-Andersen H, Larsen M. Detection of shallow detachments in central serous chorioretinopathy. Acta Ophthalmol Scand 1999;77:402-5.  Back to cited text no. 9
    

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Correspondence Address:
Pran M Kar
Department of Nephrology, Veterans Affairs Medical Center, Orlando, FL 32803
USA
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DOI: 10.4103/1319-2442.194682

PMID: 27900975

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
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