Sudden Visual Deterioration as the First Symptom of Chronic Kidney Failure

Abstract

Purpose: We report here a unique case of a sudden loss of vision as the first symptom of an advanced chronic nephropathy. Methods and Results: A 25-year-old man was referred to the Department of Ophthalmology with sudden visual deterioration presumptively diagnosed as bilateral retinitis. The patient had never been under any medical care before and had never had any clinical signs of any chronic disease. He underwent an ophthalmic examination with optical coherence tomography (OCT). Based on the clinical features, OCT scans and systemic blood pressure (BP) assessment (225/145 mm Hg), the patient was definitely diagnosed with hypertensive retinopathy and choroidopathy due to hypertensive crisis. After urgent diagnostic procedures, the patient was diagnosed with a chronic kidney disease at stage 5 in the course of chronic glomerulonephritis. Immediately, a renal replacement therapy was started and the patient was qualified for renal transplantation. Conclusion: Adolescents with an unclear picture of retinal lesions, who have neither a history nor clinical signs of a systemic disease, should undergo careful systemic screening with BP assessment. A sudden deterioration of vision may be the first symptom of a previously undiagnosed severe systemic disease (very rare chronic) that requires immediate treatment.

Hypertensive Crisis-A Serious Problem in Medical Practice

“…The patient was diagnosed with hypertensive crisis (his blood pressure was 220/140 mmHg) secondary to chronic renal disease and underwent renal transplantation from a relative [5]. This case was similar to ours of a twenty-five-year-old patient who presented with sudden bilateral reduction in vision associated with chronic kidney failure [1]. This patient was also qualified for a kidney transplant.…”

“…In our paper, we cited Kovach who described an eighteen-yearold female treated for renal disease secondary to focal segmental glomerulonephritis who developed sudden bilateral visual loss [8]. Kovach reported that glomerulonephritis may be an autoimmune disease although the fundi showed only hypertensive changes and absence of any inflammatory signs [1,8]. However, it should be underlined that clinicopathologic correlations between tissue findings in various organs, including the eyes and kidneys, have already been well-documented.…”

“…Hypertensive crisis is a life-threatening condition in which the diastolic pressure usually exceeds 120 mmHg [1,2]. The condition may occur as a hypertensive emergency with target organ damage (brain, heart, kidneys and eyes) or it may occur without target organ damage (hypertensive urgency) [3,4].…”

“…It is believed that this phenomenon is due to the higher flexibility and susceptibility of "young" blood vessels [15]. Thus, hypertensive choroidopathy typically occurs in young patients with hypertensive crises, in preeclampsia and eclampsia, in pheochromocytoma, in renal disorders [1,12,[17][18][19][20]. Choroidopathy involves disturbances at the level of the choriocapillaries, which leads to ischemic necrosis of the choroid and the retinal pigment epithelium.…”

“…"Elschnig spots" (yellow spots with dark centres), which represent foci of infarction, and "Sigerist streaks" characterized by linear spots along the choroidal vessels, which represent areas of fibrinoid necrosis. Local retinal pigment epithelial detachment (PED) and exudative retinal detachment may occur secondary to hypertensive choroidopathy [1,5,15,21,22]. Stacey and others also emphasize the value of fundus screening for the presence of hypertensive changes in patients admitted to emergency departments with concomitant visual symptoms and elevated blood pressure [15].…”