Author: Rita Basto (Portugal)
Co-authors: Júlio Almeida, Joana Roque, Susana Henriques, Graça Pires, Maria Santos
Purpose
Exudative retinal detachment (ERD) is a vision threatening retinal disorder, whose aetiology is multi-factorial. The most frequent causes involve mechanisms of external (retinal pigment epithelium and choriocapillaris) and internal (vascular endothelium) blood-retinal barrier disruption. Therefore, vascular, inflammatory and tumoral pathologies should be considered in the differential diagnosis of ERD. The aim is to illustrate the clinical features of a patient with bilateral ERD associated with pigment epithelial detachment (PED) and to clarify the association between ophthalmologic findings and systemic aspects of renal disease and dialysis.
Setting/Venue
Professor Doutor Fernando Fonseca Hospital, Amadora, Lisbon, Portugal.
Methods
Description of a case of a bilateral ERD associated with a PED, in a patient under haemodialysis, illustrated with sequential multimodal imaging techniques (ultrasonography, optic coherence tomography, retinography and angiography). A systematic literature review focusing on the clinical case was performed. Cochrane Library, PubMed and Medline databases were consulted, using the keywords “retinal detachment”, “systemic causes”, “renal disease” and “dialysis”, and the results filtered by date and relevance. The search was supplemented using the Google Scholar engine. Six case reports and two observational studies, published between 1998 and 2020, were included.
Results
A 70-year-old male presented to the emergency department with decreased vision in both eyes, more severe in the left (LE), with 3 weeks of evolution. When questioned, the patient referred unquantified weight loss in the past month. There were no other systemic and ocular symptoms. As clinical history, he presented a hypertensive end stage renal disease (ESRD) under haemodialysis and ischemic heart disease with acute myocardial infarction. Clinical observation and multimodal imaging revealed: visual acuity of 4/10 in the right eye (RE) and 1/10 in the LE; pseudophakia in both eyes, without other anterior segment changes; normal intraocular pressure; posterior segment with multiple sub-retinal white deposits; PED over the posterior pole in both eyes, with a macular giant tear of the retinal pigment epithelium (EPR) in the LE; overlying temporal peripheral ERD in the RE and temporal inferior ERD in the LE, involving the macular area. The patient was admitted for systemic evaluation and for optimization of haemodialysis parameters. Systemic inflammatory, infectious and malignant diseases were excluded. Subsequent ophthalmologic evaluation showed progressive reduction of subretinal and sub-RPE fluid with visual acuity improvement.
Conlusions
According to literature, patients with ESRD on dialysis demonstrate an increased risk of ERD, with an incidence of 0,03%. The exact pathophysiology of ERD associated with dialysis is still not well established. Some authors suggest that the focal increase in choriocapillaris permeability in the uremic state plays a more important role. In opposition, others suggest that dialysis, for causing a variation in osmolality and intermittent hemodynamic alterations, induces fluid shifts between chorioretinal layers. The aetiology of PED is also unknown. Any condition that can destabilize the complex attachment of the basement membrane of the RPE and Bruch membrane can lead to PED. The most accepted theories, associated with renal disease, are: 1) deposition of antibodies on the basement membranes and 2) secondary dysfunction of EPR due to choroidal vasculature compromise. RPE tears may complicate disorders associated with PED and cause an acute decrease in visual acuity. Multidisciplinary collaboration between ophthalmologists and nephrologists is essential for timely diagnosis and treatment. In these cases, therapy of the ERD and PED consists primarily of treating underlying systemic alterations, with correction of renal function. In some cases, laser photocoagulation was performed.
Financial Disclosure
none
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