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Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 45-50

Change in intraocular pressure in patients on hemodialysis at Ahmed Gassim dialysis center

1 Outpatient Department, Khartoum Eye Teaching Hospital, Khartoum, Sudan
2 Department of Ophthalmology, Faculty of Medicine, Al Neelain University, Khartoum, Sudan
3 Department of Glaucoma, Makkah Eye Complex, Khartoum, Sudan

Date of Submission06-Jul-2020
Date of Acceptance10-Jun-2020
Date of Web Publication27-Nov-2020

Correspondence Address:
Prof. Mahgoub Saleem
Department of Ophthalmology, Faculty of Medicine, Al Neelain University, P.O. Box 10139, Khartoum 11111
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DOI: 10.4103/bijo.bijo_10_20

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Background: Hemodialysis (HD) is common for Severe Renal dysfunction patients. Hemodialysis (HD) that may lead to change in intraocular pressure (IOP).
Objectives: The objective is to evaluate the effects of hemodialysis on IOP in patients with chronic kidney disease.
Materials and Methods: In a cross-sectional prospective hospital-based study, 100 adult Sudanese patients who were undergoing HD at Ahmed Gassim dialysis Center; August–November 2016. Portable Perkins Applanation Tonometry was done for all at two time points; pre- and post-HD. Data analysis with SPSS.
Results: Two percent of age group ≤18 years, 21% - 19–35 years, 38% - 36–50 years, 39% - >50 years. Duration of HD: <2–15 year. Seventy-six percent reported 1–2 mmHg differences in pre- and post-HD' IOPs, in 80% females and 73% males. 100% change in IOP resulted in ≤18 years, 71% in 19–35 years, 64% in 36–50 years, 88% in >50 years of age group. The commencement of HD was significantly related to the change of IOP. Hypertension, diabetes mellitus, and polycystic kidney disease had no significant differences.
Conclusion: Although there is no previous real agreement about the effect of HD on the increase of IOP; so, this study demonstrates a statistically significant increase in IOP during HD.

Keywords: Ahmed gassim dialysis center, corneal opacity, glaucoma, hemodialysis, Perkins applanation tonometer

How to cite this article:
Khalid SK, Saleem M, Allah MF. Change in intraocular pressure in patients on hemodialysis at Ahmed Gassim dialysis center. Albasar Int J Ophthalmol 2019;6:45-50

How to cite this URL:
Khalid SK, Saleem M, Allah MF. Change in intraocular pressure in patients on hemodialysis at Ahmed Gassim dialysis center. Albasar Int J Ophthalmol [serial online] 2019 [cited 2021 Oct 19];6:45-50. Available from: https://www.bijojournal.org/text.asp?2019/6/2/45/301680

  Introduction Top

Patients with severely compromised renal function: End Stage Renal Disease (ESRD); chronic kidney disease (CKD) [1] or Renal Failure (RF), constituting some of the serious public health problem worldwide, and have been associated with premature morbidity and mortality. Usually treated effectively with hemodialysis (HD) which has also some undesirable side effects.[2],[3]

These types of patients are usually highly multimorbid; having more than one disease and therefore should be carefully examined.[4] Widely varied metabolic, biochemical, and osmotic parameter can change during HD which lead to changes in some ocular function typically; visual acuity (VA) and intraocular pressure (IOP)[5] to levels that could exacerbate or increase the risk of developing glaucoma. Although it is not clear yet what was the cause of IOP changes during HD, it might be the increased production of aqueous humor or imbalance between blood and aqueous osmolarity.[5] The correlation of IOP changes and HD has been evaluated by many researchers in deferent international institutes, since long time, and pooled in the ophthalmic and nephrologic literature. However, published literature is at variance regarding the effect of HD on IOP. This remains controversial, Levy et al. and group mentioned the possibility of acute IOP rise during HD could be much more frequent than in normal controls.[6] This increase in IOP with HD was also reported by others; in case of Hu et al.'s study (2013)[7] they reported a significant increase in IOP occur in Hemodialysis, that increase the risk for glaucoma development and progression. Levy et al. postulated that the cause of changing IOP, could be due to the type of the dialysis solution, IOP decreases significantly during acetate but not bicarbonate HD infusions.[6]

On the hand other researches like Chelala et al.[5] claimed that HD leads to significant decreases of IOP postdialysis. Whereas Guijiang Sun and coresearchers claimed that there was no IOP changes at all with HD due an internal systemic compensatory mechanism to keep the IOP in its original values.[8]

  Materials and Methods Top

In a cross-sectional prospective observational hospital-based study which was conducted at Ahmed Gassim dialysis Center (AGDC), in the period between August 2016 and November 2016. Ahmed Gassim hospital in Khartoum Bahri in Sudan is a big specialized hospital; where there is thee sections: pediatric surgery, heart surgery, and Ahmed Gassim renal dialysis Center. All patients coming for hemodialysis at the center; were found to be 121 patients. One hundred Sudanese male and female patients ranged from 20 to 36 years; were selected out of the total available number. Twenty-one were excluded due to their known history of glaucoma, corneal opacity, corneal abnormalities, corneal surgery, current eye infection of those, or refused to participate. The studied patients were grouped in four age groups: according their ages and HD duration <18 years, 19–35 years, and 36–50 years >50 years' age groups. ≤18, 19–35, 36–50, and >50 years. Regarding duration of HD: <1 year, 2–5 years, 6–10 years, and within 11–15 years.

After proper explanation of the procedure, written and verbal consents, detailed standardized ophthalmic medical history and demographic data of all participants were considered and reported in the predesigned “Data Collection Forms” at the time of examination. VA was assessed roughly by finger count from close to patient's face as most of the were a pit ill to respond to proper VA checking by Snellen's Chart. Adenexa, anterior and posterior segments were checked by torch and direct Ophthalmoscope (Keeler Specialist Ophthalmoscope 2.8V,code: OP1133P1157 manufactured by Keeler direct Ophthalmic instruments; OP1133P1157; Keeler Ltd, Clewer Hill Road, Windsor, SL4 4AA UK, info@keeler.co.uk). Tonometry was done; after installing of sterile topical anesthesia and application of fluorescein dye by sterile fluorescein strips; then, IOP was checked by Portable Clement-Clarke-Model “Hand-Held Perkins Applanation Tonometer” (Manufacturer: Clement-Clarke International; Haag-Streit USA; Manufacturer Part No: 5805001).

All the 100 patients were examined in a semi-seated position at two time points; about 10 min before starting hemodialysis, to be taken as (T1), then repeated approximately “half an hour” after the finishing of hemodialysis, to be taken as (T2). Blood pressures were also measured just after the 2nd IOP measuring. The entire data were coded and entered into a Microsoft excel spreadsheet in a personal computer. Then subjected to “Statistical Analysis” by Statistical program for social sciences (SPSS) version 20 (Manufactured by IBM SPSS Inc., PASW Statistics for Windows, Version 20.0; 2009. Chicago: SPSS Inc., IL, USA). Categorical variables were analyzed using frequencies and percentage. Continuous variables were summarized using mean, percentile, range, and standard deviation. Significant differences and associations were determined by P < 0.05.

Ethical approvals were obtained from the Research and Development Center of Ahmed Gassim Hospital and Sudan Medical Specialization Board, Department of Ophthalmology. Verbal informed consents were obtained from the patients after full explanation of the study objectives and procedures; confidentiality and anonymity of each infant and family identity were adhered.

  Results Top

In the 100 Sudanese patients with end-stage CKD undergoing hemodialysis (HD); 64 (64%) of the participants were male and 36 (36%) were female [Figure 1]. The mean age of the study group was 36 years ± 19 years (range: 17–60 years). They were grouped in four groups: according their ages: (1) ≤18 year were 2 patients (2%), (2) 19–35 years were 21 patients (21%), (3) 36–50 years were 38 patients (38%), and (4) >50 years were 39 patients (39%) [Figure 2]. Twenty-four (24%) patients started their HD <1 year, 40 (40%) patients started their HD within 2–5 years, 28 (28%) patients started their HD within 6–10 years and 8 (8%) patients started their HD within 11–15 years [Figure 3]. Concomitant diseases that act as risk factor for RF; were encountered: Systemic hypertension (HTN) as risk factor found in 53 (53%) patients [Figure 4], diabetes mellitus (DM) in 12 (12%) patients [Figure 5], and only 4 (4%) have polycystic kidney disease as risk factors [Figure 6] and [Table 1].
Figure 1: Sex distribution

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Figure 2: Distribution of age groups

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Figure 3: Distribution of dialysis commencement per years

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Figure 4: Distribution of patients with predialysis hypertension

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Figure 5: Distribution of patients with predialysis diabetes mellitus

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Figure 6: Distribution of predialysis polycystic kidney diabetes mellitus

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Table 1: Correlation between each parameter and the change of intraocular pressure groups

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IOP results both pre- and post-HD were reported for each eye in the whole study group. In general, 76% of the patients (n = 76) reported some differences in pre- and post-HD' IOPs, while 24% (n = 24) did not have any discrepancy in the two readings [Figure 7]. Regarding the degrees of these disparities, 41% (n = 41 patients) had increase in IOP by 2 mmHg, and 35% (n = 35 patients) had increase in IOP by 1 mmHg [Table 1].
Figure 7: Distribution of pre- and post-dialysis intraocular pressures

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There was highly significant correlation between the change of IOP and the age groups: 100% change in in IOP results in those people ≤18 years' age, 71% change in people 19–35 years' age, 64% change in people 36–50 years' age, and finally, there was 88% difference in the IOP in the >50 years of age group [Figure 8] and [Table 1]. There was no significant gender IOP differences between males and females; as the IOP differences were reported to be 80% in females; which was slightly more; than the males result of 73% [Table 1]. The commencement of HD was significantly related to the change of IOP; as there was 62% in IOP change in patients started HD 2–5 years followed by 6–10 years (P = 0.002). HTN, DM, and polycystic kidney disease had no significant differences [Table 1].
Figure 8: Correlation between intraocular pressure and age groups

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  Discussion Top

The current study observed that the ESRD required HD at AGDC during the period were more in males (64%) than females (36%) which was in line with some international studies, such as Iseki,[9] Dinc et al.,[10] and their colleagues in Japanese populations. While this result was in contrary with others: Vrabec et al. in their Croatian study (2005), who reported the reverse, in which female were more.[4]

Kazancioǧlu from Turkey reported two opposing results in his “meeting report” article[1] for the International Society of Nephrology. Some results were with an increase, other showing decrease while rare result was of change a tall in IOP, a post-HD. All these observations were appeared in some of the current study where 76% of the patients (n = 76) reported some differences in pre-and-post HD' IOPs, while 24% did not have any differences in the both pre and post-HD' IOPs.

In the current study, there was significant relationship between the duration of HD (commencement) and the IOP changes (P = 0.002), but there was no significant correlation with IOP changes due to pre- and post-HD in each setting (P = 0.370, 0.396, respectively). Since, most of the patients in our study (68%) who reported change in IOP started HD 2–10 years (40% within 2–5 years + 28% within 6–10 years). This period looks longer than some other studies; Vrabec et al. (Zagreb, Croatia) reported IOP changes in less period; 7 months after beginning of HD.[4] Although this will not indicate significant delay in the current study as compared with Vrabec et al.; simply because this study might have been done in patients with delayed HD chances due to poor access to medical care which contribute to the increased risk of kidney disease in Sudanese patients. The same situation for polycystic kidney disease which was 4% occurrence but still had no significant value in IOP change (P = 0.946).

This current work was deferent from the study done by Doshiro et al., (Nantan General Hospital, Kyoto, Japan)[11] and co-workers to evaluate the IOP and ocular perfusion pressure (OPP) during HD, results did not support the view that: significant changes in OPP and IOP occur during HD session. Doshiro et al.[11] Jin et al. (2.4 ± 2.1 mmHg drop; 2005),[12] and Jung et al.[13] reported IOP significant decreased after HD which is against our finding. IOP changes in both studies after HD were insignificant (P = 0.958).

In this study, the predominant risk factor for ESRD, CKD, or RF that required HD was HTN. Fifty-three percent of the HD of the studied patients have systemic HTN and only 12% of the HD patients have DM. A matter which almost like Vrabec et al. (Zagreb, Croatia)[4] review comments of the predominant of HTN as risk factor for (68%). A medical impression that had been for long time (1989; Whelton and Klag 1989 of Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland, USA)[14] and supported by many other international researches like McClellan and Flanders in the USA; 2003,[15] Suleymanlar et al.in Turkey; 2011.[16]

DM in the current study constituting the second risk factor of ESRD that required HD (10%) in contrary of Lea and Nicholas study, in Atlanta-Georgia-USA; 2002,[17] which stated that: in African-American populations, the incidence of diabetes-related ESRD is four times higher than for whites, as approximately 30%–40% of all African-American patients in the USA with diabetes will develop nephropathy and many will progress to ESRD, In this current study, although HTN and DM were the risk factors for ESRD which was in line with Takamatsu et al.'s study (Japan).[18]

Regarding the change in pre- and post-HD IOP changes which was found to be 57% (41% with 2 mmh and 16% with 1 mmHg while 24% of eyes have no change). Results which were consistent with Hu J et al., (2013; Chicago USA)[7] and Goodier[19] as both reported significant increase in IOP 2.5–3.1 mmHg, 2.4 ± 2.1 mmHg, respectively. The increase of IOP was accompanied by decrease in OPP during HD, to levels that are thought to increase the risk of glaucoma development and progression.

  Conclusion Top

HD can affect various ocular parameters. This is particularly true of IOP. There is significant change in the IOP measurement before and after hemodialysis in most patients by ± 2 mmHg. Age and duration of hemodialysis significantly affect it.


To increase awareness of patients and clinicians about the IOP change during HD.

Promptly, ophthalmic checkup of HD patients for early detection of IOP change and glaucoma.

More national studies must be done.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kazancioǧlu R. Risk factors for chronic kidney disease: An update. Kidney Int Suppl (2011) 2013;3:368-71.  Back to cited text no. 1
Tawara A. Intraocular pressure during hemodialysis. J UOEH 2000;22:33-43.  Back to cited text no. 2
Mansour DE, El-Bayomi AM, El-Azab AM. Abnormal Ocular findings in chronic renal failure patients on hemodialysis. Egypt J Hospital Med 2018;72:5640-6.  Back to cited text no. 3
Vrabec R, Vatavuk Z, Pavlović D, Sesar A, Cala S, Mandić K, et al. Ocular findings in patients with chronic renal failure undergoing haemodialysis. Coll Antropol 2005;29 Suppl 1:95-8.  Back to cited text no. 4
Chelala E, Dirani A, Fadlallah A, Slim E, Abdelmassih Y, Fakhoury H, et al. Effect of hemodialysis on visual acuity, intraocular pressure, and macular thickness in patients with chronic kidney disease. Clin Ophthalmol 2015;9:109-14.  Back to cited text no. 5
Levy J, Tovbin D, Lifshitz T, Zlotnik M, Tessler Z. Intraocular pressure during haemodialysis: A review. Eye (Lond) 2005;19:1249-56.  Back to cited text no. 6
Hu J, Kelly M. Bui KM, Kevin H. Patel KH, Kim H, Arruda JAL, Wilensky JT, Vajaranant TS. Effect of Hemodialysis on Intraocular Pressure and Ocular Perfusion Pressure. JAMA Ophthalmol. 2013;131:1525-1531. doi:10.1001/jamaophthalmol.2013.5599.  Back to cited text no. 7
Sun G, Hao R, Zhang L, Shi X, Hei K, Dong L, et al. The effect of hemodialysis on ocular changes in patients with the end-stage renal disease. Ren Fail 2019;41:629-35.  Back to cited text no. 8
Iseki K. Factors influencing the development of end-stage renal disease. Clin Exp Nephrol 2005;9:5-14.  Back to cited text no. 9
Dinc UA, Ozdek S, Aktas Z, Guz G, Onol M. Changes in intraocular pressure, and corneal and retinal nerve fiber layer thickness during hemodialysis. Int Ophthalmol 2010;30:337-40.  Back to cited text no. 10
Doshiro A, Ban Y, Kobayashi L, Yoshida Y, Uchiyama H. Intraocular pressure change during hemodialysis. Am J Ophthalmol 2006;142:337-9.  Back to cited text no. 11
Jin QM, Yu seconds C, Hongwei Z, Jianxiong C. Changes of intraocular pressure during hemodialysis in patients with chronic renal failure intraocular pressure fluctuation during hemodialysis in chronic renal failure patients. J Ophthalmol Republic China 2005;44:96-103.  Back to cited text no. 12
Jung JW, Yoon MH, Lee SW, Chin HS. Effect of hemodialysis (HD) on intraocular pressure, ocular surface, and macular change in patients with chronic renal failure. Effect of hemodialysis on the ophthalmologic findings. Graefes Arch Clin Exp Ophthalmol 2013;251:153-62.  Back to cited text no. 13
Whelton PK, Klag MJ. Hypertension as a risk factor for renal disease. Review of clinical and epidemiological evidence. Hypertension 1989;13:I19-27.  Back to cited text no. 14
McClellan WM, Flanders WD. Risk factors for progressive chronic kidney disease. J Am Soc Nephrol 2003;14:S65-70.  Back to cited text no. 15
Süleymanlar G, Utaş C, Arinsoy T, Ateş K, Altun B, Altiparmak MR, Ecder T, Yilmaz ME, Çamsari T, Başçi A, Odabas AR, Serdengeçti K. A population-based survey of Chronic Renal Disease in Turkey—the CREDIT study. Nephrol Dial Transplant (2011) 26: 1862–1871 doi: 10.1093/ndt/gfq656. Re-Accessed 27.10.2020.  Back to cited text no. 16
Lea JP, Nicholas SB. Diabetes mellitus and hypertension: Key risk factors for kidney disease. J Natl Med Assoc 2002;94:7S-15S.  Back to cited text no. 17
Takamatsu N, Abe H, Tominaga T, Nakahara K, Ito Y, Okumoto Y, et al. Risk factors for chronic kidney disease in Japan: A community-based study. BMC Nephrol 2009;10:34.  Back to cited text no. 18
Hu J, Kelly M. Bui KM, Kevin H. Patel KH, Kim H, Arruda JAL, Wilensky JT, Vajaranant TS. Effect of Hemodialysis on Intraocular Pressure and Ocular Perfusion Pressure. JAMA Ophthalmol. 2013;131:1525-1531. doi:10.1001/jamaophthalmol.2013.5599.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1]


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