CC BY-NC-ND 4.0 · Ann Natl Acad Med Sci 2022; 58(04): 189-196
DOI: 10.1055/s-0042-1757736
Original Article

Analytical Study of Ocular Surface Changes in Patients of Chronic Kidney Disease undergoing Hemodialysis and Peritoneal Dialysis

Shashi Ahuja
1   Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Shilpa Jalwaniya
1   Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Sreejith Parameswaran
2   Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Sonali Sarkar
3   Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Ramesh Ananthkrishnan
4   Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Debasis Gochhait
5   Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
› Author Affiliations
Funding The research project was supported by institutional grants from Lady Tata Memorial Trust.


Objectives The idiopathic group is a significant cause of chronic kidney disease (CKD) in developing countries. Literature available on ocular surface changes has predominantly been reported in patients undergoing hemodialysis. Little is known about the changes in patients undergoing peritoneal dialysis. The present study aimed to identify ocular surface changes in an idiopathic group of CKD undergoing dialysis.

Aim To compare tear film disorders and the severity of ocular surface changes (goblet cell density, squamous metaplasia, and corneoconjunctival calcification) in patients of idiopathic etiology with CKD undergoing hemodialysis and peritoneal dialysis. This is an analytical study.

Materials and Methods Asymptomatic adult patients of idiopathic CKD, on treatment with dialysis underwent comprehensive ophthalmic examination, including best-corrected visual acuity, slit-lamp examination, and a dilated fundus examination. Dry eye assessment was done by ocular surface staining score, Schirmer test, and tear breakup time (TBUT). Conjunctival impression cytology was studied to assess changes on ocular surface. Chest X-rays for aortic calcification were reviewed and data analyzed.

Results Both eyes of 76 patients of hemodialysis and 32 patients of peritoneal dialysis were studied. Ocular surface staining (OSS) scores were low. Impression cytology showed a drop in goblet cell density, presence of squamous metaplasia, and conjunctival keratinization significantly more in the hemodialysis group. No correlation was seen between the presence of conjunctival calcification and aortic calcification.

Conclusion The hemodialysis group had mild subclinical dry eye but keratinization of conjunctiva was seen. Similarly, advanced squamous metaplasia was seen in the peritoneal dialysis group. These changes were positively correlated to decrease in goblet cell density.

Publication History

Article published online:
04 December 2022

© 2022. National Academy of Medical Sciences (India). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Jha V, Garcia-Garcia G, Iseki K. et al. Chronic kidney disease: global dimension and perspectives. Lancet 2013; 382 (9888): 260-272
  • 2 Dialysis P., Health N.. Peritoneal Dialysis | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases; 2022
  • 3 Evans RD, Rosner M. Ocular abnormalities associated with advanced kidney disease and hemodialysis. Semin Dial 2005; 18 (03) 252-257
  • 4 Ebana Mvogo SR, Fouda Menye HD, Dohvoma VA. et al. Mesure de la sécrétion lacrymale chez des patients hémodialysés chroniques à l'hôpital général de Douala-Cameroun. [Measurement of lacrimal secretion in chronic hemodialysis patients at Douala General Hospital - Cameroon] J Fr Ophtalmol 2019; 42 (03) 244-247
  • 5 Charlton JF, Schwab IR, Stuchell R. Tear hyperosmolarity in renal dialysis patients asymptomatic for dry eye. Cornea 1996; 15 (04) 335-339
  • 6 Li DQ, Chen Z, Song XJ, Luo L, Pflugfelder SC. Stimulation of matrix metalloproteinases by hyperosmolarity via a JNK pathway in human corneal epithelial cells. Invest Ophthalmol Vis Sci 2004; 45 (12) 4302-4311
  • 7 Miljanović B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 2007; 143 (03) 409-415
  • 8 Chen H, Zhang X, Shen X. Ocular changes during hemodialysis in patients with end-stage renal disease. BMC Ophthalmol 2018; 18 (01) 208
  • 9 Bakaris S, Ozdemir M, Isik IO, Buyukbese MA, Ozdemir G. Impression cytology changes and corneoconjunctival calcification in patients with chronic renal failure. Acta Cytol 2005; 49 (01) 1-6
  • 10 Kianersi F, Taheri S, Fesharaki S. et al. Ocular manifestations in hemodialysis patients: Importance of ophthalmic examination in prevention of ocular sequels. Int J Prev Med 2019; 10: 20
  • 11 Singh R, Joseph A, Umapathy T, Tint NL, Dua HS. Impression cytology of the ocular surface. Br J Ophthalmol 2005; 89 (12) 1655-1659
  • 12 Haller-Schober EM, Schwantzer G, Berghold A, Fischl M, Theisl A, Horwath-Winter J. Evaluating an impression cytology grading system (IC score) in patients with dry eye syndrome. Eye (Lond) 2006; 20 (08) 927-933
  • 13 Pahor D, Hojs R, Graner B. Conjunctival and corneal changes in chronic renal failure patients treated with maintenance hemodialysis. Ophthalmologica 1995; 209 (01) 14-6
  • 14 Jalal T, Faouzi H, Faten T, Abdellatif A, Mahdouani K. Oeil et epuration extra renale [Ocular complications in peritoneal haemodialysis]. Tunis Med 2005; 83 (10) 617-621
  • 15 Vitali C, Moutsopoulos HM, Bombardieri S. The European Community Study Group on diagnostic criteria for Sjögren's syndrome. Sensitivity and specificity of tests for ocular and oral involvement in Sjögren's syndrome. Ann Rheum Dis 1994; 53 (10) 637-647
  • 16 Hay EM, Thomas E, Pal B, Hajeer A, Chambers H, Silman AJ. Weak association between subjective symptoms or and objective testing for dry eyes and dry mouth: results from a population based study. Ann Rheum Dis 1998; 57 (01) 20-24
  • 17 Vanley GT, Leopold IH, Gregg TH. Interpretation of tear film breakup. Arch Ophthalmol 1977; 95 (03) 445-448
  • 18 Taskapili M, Serefoglu Cabuk K, Aydin R. et al. The effects of hemodialysis on tear osmolarity. J Ophthalmol 2015; 2015: 170361
  • 19 Aktaş Z, Ozdek S, Asli Dinç U. et al. Alterations in ocular surface and corneal thickness in relation to metabolic control in patients with chronic renal failure. Nephrology (Carlton) 2007; 12 (04) 380-385
  • 20 Doughty MJ. Contact lens wear and the development of squamous metaplasia of the surface cells of the conjunctiva. Eye Contact Lens 2011; 37 (05) 274-281
  • 21 Chen YT, Li S, Nikulina K, Porco T, Gallup M, McNamara N. Immune profile of squamous metaplasia development in autoimmune regulator-deficient dry eye. Mol Vis 2009; 15: 563-576
  • 22 Demir N, Altay M, Ozer E. et al. Duration of renal failure as risk factor for conjunctival squamous metaplasia. Acta Cytol 2008; 52 (03) 309-312
  • 23 Murube J, Rivas L. Biopsy of the conjunctiva in dry eye patients establishes a correlation between squamous metaplasia and dry eye clinical severity. Eur J Ophthalmol 2003; 13 (03) 246-256
  • 24 De Paiva CS, Villarreal AL, Corrales RM. et al. Dry eye-induced conjunctival epithelial squamous metaplasia is modulated by interferon-gamma. Invest Ophthalmol Vis Sci 2007; 48 (06) 2553-2560
  • 25 Cobo G, Lindholm B, Stenvinkel P. Chronic inflammation in end-stage renal disease and dialysis. Nephrol Dial Transplant 2018; 33 (suppl_3): iii35-iii40
  • 26 Destefanis S, Giretto D, Muscolo MC. et al. Clinical evaluation of a nutraceutical diet as an adjuvant to pharmacological treatment in dogs affected by Keratoconjunctivitis sicca. BMC Vet Res 2016; 12 (01) 214
  • 27 Tseng SC, Hirst LW, Maumenee AE, Kenyon KR, Sun TT, Green WR. Possible mechanisms for the loss of goblet cells in mucin-deficient disorders. Ophthalmology 1984; 91 (06) 545-552
  • 28 Maumenee AE. Keratinization of the conjunctiva. Trans Am Ophthalmol Soc 1979; 77: 133-143
  • 29 Nelson JD, Havener VR, Cameron JD. Cellulose acetate impressions of the ocular surface. Dry eye states. Arch Ophthalmol 1983; 101 (12) 1869-1872
  • 30 Nakamura T. Molecular mechanism of pathological keratinization in severe ocular surface diseases [article in Japanese]. Nippon Ganka Gakkai Zasshi 2004; 108 (11) 654-664
  • 31 Stibor V, Lachmanová J, Povýsil C. Changes in the conjunctiva and cornea in dialyzed patients [article in Czech]. Cesk Slov Oftalmol 1996; 52 (05) 286-290
  • 32 Ozdemir M, Bakaris S, Ozdemir G, Buyukbese MA, Cetinkaya A. Ocular surface disorders and tear function changes in patients with chronic renal failure. Can J Ophthalmol 2004; 39 (05) 526-532
  • 33 Vignanelli M, Stucchi CA. Conjunctival calcification in patients in chronic hemodialysis. Morphologic, clinical and epidemiologic study [article in French]. J Fr Ophtalmol 1988; 11 (6-7): 483-492