Managing Glaucoma in Dialysis Patients
Prostaglandin analogs should be the first-line therapy for glaucoma in dialysis patients, while topical carbonic anhydrase inhibitors must be avoided due to significant risks of metabolic acidosis and accelerated progression to long-term dialysis. 1, 2
First-Line Medication Selection
Prostaglandin analogs are the preferred initial therapy because they are the most effective at lowering intraocular pressure (IOP), well-tolerated, and require only once-daily dosing, making them ideal for patients with complex medical regimens. 1, 3
Beta-blockers (such as timolol) represent a reasonable alternative, though they require careful consideration of systemic absorption and potential cardiovascular effects in patients with renal disease. 1
Alpha-2 adrenergic agonists and parasympathomimetics can be considered as adjunctive or alternative agents when prostaglandins are insufficient or contraindicated. 4
Critical Medication to Avoid
Topical carbonic anhydrase inhibitors (dorzolamide, brinzolamide) should be avoided in dialysis patients and those with advanced chronic kidney disease. 2
A nationwide population-based study demonstrated that topical CAI users with advanced CKD had significantly higher risks of long-term dialysis (adjusted hazard ratio = 1.17) and metabolic acidosis (adjusted hazard ratio = 1.89) compared to non-users. 2
Even topical administration can cause systemic absorption sufficient to inhibit extraocular carbonic anhydrase isoenzymes, leading to metabolic acidosis and normocytic anemia in patients with impaired renal function. 5
Systemic carbonic anhydrase inhibitors (oral/IV acetazolamide) are absolutely contraindicated in dialysis patients due to dependence on renal clearance and propensity for severe metabolic acidosis. 6, 7
Target IOP and Monitoring Strategy
Set target IOP at approximately 20% below baseline mean measurements to prevent glaucomatous damage while accounting for the unique hemodynamic challenges in dialysis patients. 4, 1
Monitor IOP and blood pressure during hemodialysis sessions in patients with established glaucoma or high-risk features, as dialysis causes significant IOP elevation (mean increase 3.1 mm Hg) and decreased ocular perfusion pressure. 8
During hemodialysis, 53-71% of patients reach ocular perfusion pressure thresholds associated with increased glaucoma progression risk, even when office IOP appears well-controlled. 8
Medication Administration Technique
Instruct patients on nasolacrimal duct occlusion or eyelid closure for 3-5 minutes after drop instillation to minimize systemic absorption—particularly important in renal patients who cannot clear medications normally. 4, 1
When multiple drops are prescribed, patients must wait at least 5 minutes between different medications to ensure adequate absorption and prevent washout. 1
Link eye-drop administration to daily activities and provide repeated instruction, as nearly 45% of patients take fewer than 75% of prescribed doses even with optimal support. 1
Special Considerations for Dialysis Patients
Coordinate timing of glaucoma medications around dialysis schedules to avoid peak drug levels during periods of hemodynamic instability. 8
Consider laser trabeculoplasty as an alternative or adjunct to medications in patients with adherence concerns or those at risk of losing continuous follow-up care. 4
Fixed-combination therapies may improve adherence by reducing drop burden, which is especially valuable in patients managing multiple systemic medications for renal disease. 4
Common Pitfalls to Avoid
Do not assume topical glaucoma medications are "safe" in renal patients—topical CAIs carry real systemic risks that can accelerate dialysis dependence. 2
Do not rely solely on office IOP measurements—dialysis-related IOP spikes and perfusion pressure drops occur between visits and contribute to progression. 8
Do not prescribe acetazolamide for acute angle-closure or perioperative IOP control in dialysis patients, as renal clearance is eliminated and toxic accumulation with severe acidosis will occur. 6, 7