What is the immediate management for a patient with end-stage renal disease (ESRD) on hemodialysis (HD) who experiences a retinal hemorrhage, potentially due to diabetic retinopathy or hypertension?

Management of Retinal Hemorrhage in Hemodialysis Patients

Immediately refer the patient to an experienced ophthalmologist for urgent evaluation and treatment, while temporarily modifying or eliminating systemic anticoagulation during hemodialysis until the retinal hemorrhage is stabilized. 1, 2

Immediate Actions

Ophthalmologic Referral

• Promptly refer patients with any retinal hemorrhage to an ophthalmologist who is knowledgeable and experienced in managing diabetic retinopathy and retinal complications. 1
• This referral should occur regardless of the severity of retinopathy, as retinal hemorrhage in dialysis patients represents a vision-threatening emergency 1, 3
• The ophthalmologist will determine if the hemorrhage represents proliferative diabetic retinopathy, vitreous hemorrhage, or other sight-threatening conditions requiring immediate intervention 1

Hemodialysis Anticoagulation Modification

• For patients with active retinal hemorrhage or within 2 weeks of retinal hemorrhage, completely avoid systemic anticoagulation during hemodialysis. 2
• Use heparin-free hemodialysis, peritoneal dialysis, or regional anticoagulation with prostacyclin, mesilates, or citrate instead of standard heparin protocols 2
• Patients with incompletely treated proliferative diabetic retinopathy should also receive dialysis without systemic anticoagulation 2

Blood Pressure and Metabolic Control

Optimize Systemic Parameters

• Aggressively control blood pressure to targets <140/90 mmHg to reduce retinopathy progression and prevent further hemorrhage. 1
• Lower targets (<130/80 mmHg) may be appropriate for patients with significant albuminuria or advanced retinopathy 1
• Optimize glycemic control to reduce risk of retinopathy progression, though this is a longer-term strategy 1
• Control serum lipids, as dyslipidemia contributes to retinopathy progression 1

Timing Considerations

• Schedule ophthalmologic examinations on non-dialysis days or immediately before hemodialysis sessions, as hemodialysis causes significant ocular changes including decreased macular thickness and altered intraocular pressure 4
• These changes can affect examination quality and visual acuity assessment 4

Ophthalmologic Treatment Options

Definitive Interventions

• Panretinal laser photocoagulation is indicated for high-risk proliferative diabetic retinopathy to reduce vision loss risk. 1
• Intravitreous anti-VEGF injections (ranibizumab) are non-inferior to laser photocoagulation for proliferative diabetic retinopathy 1
• Focal laser photocoagulation is indicated for clinically significant macular edema 1
• Intravitreal anti-VEGF therapy is suitable for vision-threatening diabetic macular edema 1
• Corticosteroids can be used locally for vision-threatening diabetic retinopathy and macular edema 1

Common Pitfalls and Caveats

Aspirin Therapy

• The presence of retinopathy or retinal hemorrhage is NOT a contraindication to aspirin therapy for cardioprotection. 1
• Aspirin does not increase the risk of retinal hemorrhage 1
• However, systemic heparin anticoagulation during hemodialysis does increase bleeding risk and should be modified as noted above 2

Monitoring After Dialysis Initiation

• Diabetic retinopathy activity typically decreases relatively early after hemodialysis initiation, with over 95% of patients showing low activity by 6 months 5
• However, vigilant monitoring is still required as some patients may experience worsening 5
• Hemodialysis causes acute changes in subfoveal choroidal thickness, retinal vessel caliber, and other ocular parameters that are generally well-tolerated but require awareness 6

High-Risk Features Requiring Urgent Action

• Sudden vision loss or retinal detachment requires immediate ophthalmologic referral 1
• Severe nonproliferative diabetic retinopathy, any proliferative diabetic retinopathy, or any degree of macular edema warrants prompt specialist evaluation 1
• Patients with incompletely treated proliferative diabetic retinopathy are at particularly high bleeding risk during standard hemodialysis 2