|Year : 2020 | Volume
| Issue : 2 | Page : 155-159
Ocular manifestations in patients with diabetes with end-stage renal disease
Nagbhushan Chougule, Umesh Harakuni, Rolika Bansal, Lisa Sunny
Department of Ophthalmology, Karnatak Lingayat Education Academy of Higher Education and Research, Belagavi, Karnataka, India
|Date of Submission||28-Apr-2019|
|Date of Acceptance||22-Apr-2020|
|Date of Web Publication||23-Jun-2020|
Dr. Nagbhushan Chougule
House Number 201, Magnolia 2 Building, Near Congress Well, M. G. Colony, Tilakwadi, Belgavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
PURPOSE: Diabetic nephropathy is the most common cause of kidney failure and end-stage kidney disease. The present study was undertaken to find ocular changes and complications associated with diabetic end-stage kidney disease.
MATERIALS AND METHODS: A 1-year cross-sectional study was conducted in the department of ophthalmology at a tertiary care hospital in South India between January 2008 and December 2008 on 50 patients with diabetes mellitus undergoing renal hemodialysis. Patients were subjected to general physical examination, systemic examination, and ocular examination. Best-corrected visual acuity, intraocular pressure, and detailed examination of anterior and posterior segments were assessed.
RESULTS: Male (74%) preponderance was observed, and 50% of the patients had age more than 60 years. Thirty-two (32%) of the patients had duration of renal dialysis <6 months. Twenty-six (26%) eyes had duration of vision loss within a year with duration of diabetes up to 4 years. Blurring of vision was the most important symptom noticed among the patients. Patients with decreased vision <6/24 were about 47%. Fifty-three percent of the patients had vision of 6/6–6/18. Eighty percent of the eyes had diabetic retinopathy in one or the other form. Overall ocular changes seen in patients were diabetic retinopathy (48%), hypertensive retinopathy (12%), and cataract (9%). Proliferative diabetic retinopathy was the most common (50%) cause of visual impairment.
CONCLUSION: Patients with diabetic end-stage kidney diseases are at high risk of ocular morbidities. Timely screening and treatment may help to reduce the ocular morbidities in this group.
Keywords: Diabetes mellitus, diabetic nephropathy, diabetic retinopathy, end-stage kidney disease
|How to cite this article:|
Chougule N, Harakuni U, Bansal R, Sunny L. Ocular manifestations in patients with diabetes with end-stage renal disease. Indian J Health Sci Biomed Res 2020;13:155-9
|How to cite this URL:|
Chougule N, Harakuni U, Bansal R, Sunny L. Ocular manifestations in patients with diabetes with end-stage renal disease. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2020 Aug 3];13:155-9. Available from: http://www.ijournalhs.org/text.asp?2020/13/2/155/287424
| Introduction|| |
Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to absolute or relative deficiency of insulin. In the modern era, diabetes mellitus is a burning issue. In the long term, it leads to microvascular complications such as neuropathy, retinopathy, and nephropathy. Diabetes affects the vasculature in the retina and kidneys. Diabetic nephropathy is a progressive kidney disorder. Diabetic nephropathy is the most common cause of kidney failure and end-stage kidney disease.
Chronic renal failure (CRF) is an irreversible and progressive process that results in end-stage renal disease (ESRD) where a patient has to be dependent on renal replacement therapy for survival. Deterioration of eyesight is due to diabetic retinopathy, ischemic optic neuropathy, central retinal vein occlusion, and cortical blindness. Ocular morbidity may be directly due to hypertension, uremia, or anemia; some are related to the causes leading to CRF. Some effects are due to hemodialysis.
Retinopathy is often asymptomatic in its most treatable stage; a delay in diagnosis can result in a significant increase in the patient's risk of visual loss. The ocular condition is also an indicator of the metabolic control of the disease process. Similarly, an unknown case of CRF, with its ocular complications, may first present to an ophthalmologist.
In view of the above, this study was undertaken to evaluate the ocular manifestations and their outcome and complications associated with diabetic ESRD and to evaluate the ocular status along with duration of diabetes in ESRDs that is CRF.
| Materials and Methods|| |
Approval for this study was obtained from the institutional review board and ethics committee. The study adhered to the tenets of the Declaration of Helsinki. The 1-year cross-sectional study was conducted in a tertiary care hospital in South India on 50 patients with diabetes mellitus who were on renal hemodialysis during the period of January 2008 to December 2008.
All patients with diabetes diagnosed to have CRF in diabetes mellitus undergoing renal dialysis were included in the study and were included on the basis of universal sampling method. Patients with comatose status, who are not willing to undergo procedures, were excluded from the study.
After finding the suitability as per se lection criteria, patients were selected for the study and briefed about the nature of the study, and written informed consent was obtained. Further, descriptive data of the participants, such as name, age, gender, and detailed history, were obtained by interviewing the participants, and clinical examination and necessary investigations were recorded on predesigned and pretested pro forma.
All the eligible patients were subjected to detailed examination such as history, general physical examination, systemic examination, and ocular examination including best-corrected visual acuity recorded, intraocular pressure, and detailed examination of anterior and posterior segments.
Pupil dilatation was performed with tropicamide for indirect ophthalmoscopy with 20D lens. Macular edema was classified on the basis of early treatment diabetic retinopathy study. Other investigations such as fundus fluorescein angiography, perimetry, fundus photography, and Schirmer's test were carried out wherever indicated.
Further, patients underwent laboratory tests for hemoglobin, total leukocyte count, differential leukocyte count, erythrocyte sedimentation rate, serum urea, and serum creatinine levels. Special investigations such as serum calcium, serum electrolytes, and urine routine and microscopic examination were carried out on the patients if necessary.
The Chi-square test was used to determine the relationship between ocular findings with duration of renal dialysis in diabetic end-stage kidney diseases.
| Results|| |
In our study with 100 eyes of 50 patients, a male preponderance was observed. There were 74% of males and 26% of females, with a male-to-female ratio of 2.84:1, and their age ranged from 28 to 69 years. Fifty percent of the patients were in the age group of more than 60 years, followed by 34% in 46–60 years and 14% in 31–45 years. Two percent of the patients belonged to the age group of 25–30 years.
Most of the patients (32%) underwent dialysis for <6 months, followed by 6–12 months (24%), 12–18 (16%), 18–24 months, and more than 24 months (14% each). Patients undergoing dialysis for more than 2 years constituted 14% and for < 2 years were 32%. The remaining 24% of the patients had duration between 6 and 12 months and 16% of the patients had 12–18 months. The duration of diabetes mellitus ranged from 1 year to 20 years, and the duration of vision loss ranged from 1 week to 10 years. Twenty-six eyes had duration of vision loss within a year with duration of diabetes up to 4 years, 16 eyes had vision loss with diabetic duration of 5–9 years, and 12 eyes had vision loss between 1 and 2 years with diabetic duration of more than 15 years.
Blurring of vision (decrease in good vision) was the most important symptom complained by patients. Patients with decreased vision <6/24 were about 47%. Most of them were of gradual onset and the remaining patients had vision of 6/6–6/18 in 53% [Table 1]. Out of 100 eyes, 80% of the eyes had diabetic retinopathy in one or the other form, and some of these were associated with other symptoms which had close correlation to diabetic retinopathy [Table 2].
|Table 1: Best-corrected visual acuity in the eyes of patients with diabetes mellitus in end-stage renal disease|
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|Table 2: Severity of diabetic retinopathy studied in diabetes mellitus patients with end-stage kidney disease|
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In patients with diabetes mellitus having end-stage kidney disease, the cataractous lens (Grade II–IV nuclear sclerosis [NS]) and posterior subcapsular cataract were present in 53%. In the remaining, 25% of the patients had undergone cataract surgery with pseudophakia and 22% had clear lens.
Diabetic retinopathy was seen commonly among the patients (48%) with diabetes mellitus having end-stage kidney disease, followed by 12% with hypertensive retinopathy. The other ocular findings noted were as follows: cataract in 9% of patients, maculopathy in 5%, 4% each had tractional retinal detachment and vitreous hemorrhage, and 2% each had papilledema, glaucoma, and age-related macular degeneration (ARMD). In 12% of the patients, no ocular findings were recorded [Table 3].
|Table 3: Ocular changes with duration of diabetes mellitus seen in end-stage kidney disease group of patients|
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With the duration of dialysis <1 year, the ratio of number of eyes with ocular changes and number of eyes without ocular changes was 4.14:1. However, after 1-year duration, this ratio increased to 28:1 indicating a sixfold increase in complications. These finding were statistically significant (P < 0.05) [Table 4].
|Table 4: Ocular complications in relation to duration of renal dialysis duration|
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In the present study, proliferative diabetic retinopathy (PDR) was the most common (50%) cause of visual impairment. The other causes of visual impairment were cataract (17%), optic neuropathy (3.84%), maculopathy (9.61%), and retinal detachment (7.60%). The other causes such as ARMD and vitreous hemorrhage contributed to 11.53% as causes of visual impairment [Table 5].
| Discussion|| |
Diabetes mellitus, justifiably known as the “devil,” affects almost every tissue and cell in the human body. Diabetic retinopathy, once placed 17th amongst the cause of blindness has rapidly ascended to become the third cause, while diabetic nephropathy remains the most common cause of end stage kidney disease.
These ocular complications such as retinopathy which are microvascular complications are innocuous in onset, progressively destructive in their course, and are remediable only to a certain extent. Unfortunately, most often, they are symptomatically evident, i.e., when considerable damage has occurred and when restoration of anatomical and physiological function to normal is impossible.
Over the years, voluminous information has been accumulated on the pathogenesis of diabetic complications such as retinopathy. Many clinical trials and researches have yielded fruitful results. These results are, however, not being effectively transferred between ophthalmologists, nephrologists, and physicians, to benefit the patients.
In the present study, male preponderance was seen. There were 74% of males and 26% of females. Similar findings were reported in a study, that is, the overall male: female ratio in CRF was 2.8:1, which was similar to worldwide data. The age ranged from 28 to 69 years. Fifty percent of the patients were in the age group of more than 60 years, followed by 34% in 46–60 years and 14% in 31–45 years. The age group more than or equal to 60 years is more prone to metabolic disorder like diabetes mellitus which leads to diabetic nephropathy and deteriorates to end-stage of CRF. Similar findings were reported by authors in various studies done previously. The study showed that the incidence of ESRD increases with advancing age of the patient.
This study documented that patients with increased age have diabetes mellitus, which leads to diabetic nephropathy and then CRF with other associated factors such as hypertension, glomerulonephritis, and polycystic kidney diseases. These risk factors were more prevalent in elderly males leading to CRF.
Arteriolar hyalinosis which occurs as a physiological change with advancement of age and its association with hypertension leads to capillary closure downstream and pathological changes in retinal and renal vasculature. This is enhanced in diabetes mellitus., Hence, this study confirms the close relationship between renal dialysis, diabetes mellitus, and lifespan of patients in CRF. This also shows ocular diabetic changes which lead to ocular complications. The same ocular manifestations were seen in this study group.
In our study, 14% of the patients had duration of dialysis more than 2 years and 32% of the patients had duration of <6 months. The remaining 24% of the patients had duration between 6 and 12 months and 16% of the patients had 12–18 months. It was observed that as the duration of dialysis increased, the number of patients undergoing dialysis declined. This could be attributed to patients' poor compliance, low socioeconomic status, uncontrolled diabetes mellitus, hypertension, anemia, secondary infections, and mortality.
In this study, the duration of diabetes mellitus ranged from 1 year to 20 years and the duration of visual loss ranged from 1 week to 10 years. Twenty-six (26%) eyes had duration of visual loss within 1 year with duration of diabetes up to 4 years. The blurring of vision (decrease in good vision) was the most important symptom. Patients with decreased vision <6/24 were about (47%). The remaining 53% of the patients had vision of 6/6–6/18. Similar findings were reported in another study.
In this study, out of 100 eyes, 80% of the eyes had diabetic retinopathy in one or the other form. Visual loss increases with an increase in duration of diabetes mellitus, and this was more in patients undergoing renal dialysis. Similar findings have been observed by various studies in the literature. The studies inferred that the incidence of diabetic retinopathy increases with duration of diabetes mellitus. Patients having diabetes mellitus and undergoing renal dialysis showed an association of 49% with diabetic retinopathy. The severity of retinopathy increases with nephropathy.
In patients with diabetes mellitus having end-stage kidney disease, the cataractous lens (Grade II–IV NS) and posterior subcapsular cataract were present in 53%. In the remaining, 25% of the patients had undergone cataract surgery with pseudophakia and 22% of the patients had clear lens. The findings of this study suggest that with advancing age, visual loss was associated with the cataractous changes in lens and diabetic retinopathy. Some patients underwent intraocular implant surgeries, and further studies are required to see whether diabetic retinopathy progressed with intraocular lens implantation.
Diabetic retinopathy was seen commonly among patients (48%) with diabetes mellitus having end-stage kidney disease, followed by 12% with hypertensive retinopathy. Thirteen percent of the diabetic retinopathy patients had maculopathy, vitreous hemorrhage, and retinal detachment. Two percent of the patients had papilledema in a hypertensive group because of the accelerated hypertension. There were 2% glaucoma suspects which required further follow-up and treatment. Based on previous reports, the most common cause of renal failure is diabetes mellitus, followed by hypertension. Similar findings have been reported in another hospital-based study conducted to evaluate ocular findings in patients with CRF.
In the present study, PDR was the most common (50%) cause of visual impairment. The other causes of visual impairment were cataract (17%), optic neuropathy (3.84%), maculopathy (9.61%), and retinal detachment (7.60%). The other causes such as ARMD and vitreous hemorrhage contributed 11.53% as causes of visual impairment. A study confirms similar findings in the literature.
In patients of diabetes mellitus, renal dialysis is known to aggravate retinopathy, especially vitreous hemorrhage, retinal detachment, and clinically significant macular edema. This effect might be mediated through the increase in blood pressure, fibrinogen levels, and raised lipoproteins. The severity of diabetic retinopathy is seen due to the unique histological structure and metabolic activity of the retina, which is susceptible to noxious stimuli resulting from hypertensive and uremic changes of diabetic nephropathy in CRF in renal dialysis.
Ocular complications are still not reduced in spite of newer advances in the treatment of diabetic retinopathy and ESRD. This is due to the poor longevity of patients with CRF and advancing stages of the disease. Thus, it requires thorough biochemical investigations, renal profile, and management of diabetic retinopathy to prevent its complications.
Patients on renal dialysis have life expectancy of < 3–5 years. In Indian scenario, it is reduced further due to low socioeconomic status, irregular medications, mental and physical instability, poor compliance, improper care, protein malnutrition, and lack of knowledge. Hence, patients are on irregular periods of renal dialysis, due to which it deteriorates the life of the patient. Early referral of patients with diabetic end-stage kidney disease may bring to surface a retinal lesion, where an ophthalmologist's intervention and appropriate management might prevent loss of vision.
Care of diabetic patients is a demanding task. It requires intense attention to multiple details. In addition to members of the dialysis team, representatives of other specialties (for example, vascular surgeon, neurologist, and utmost ophthalmologist) are needed. The existence of a diabetic team from all subspecialties should work in coordination with nephrologists. Patients should be educated and informed about the importance of eyes and kidneys. Patients on CRF and renal dialysis with diabetes mellitus are informed about the importance of ocular examination, with detailed ophthalmic tests conducted whenever necessary. They should be screened and detected and properly treated with all possibilities.
| Conclusion|| |
To conclude, patients with diabetic end stage kidney diseases are at high risk of ocular manifestations. Hence, timely screening and treatment may help to reduce the ocular morbidities in this group.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]