Central Retinal Artery Occlusion Following Intradialytic Hypotension in End-Stage Renal Disease

Central retinal artery occlusion (CRAO) is a vision-threatening ophthalmic emergency requiring rapid recognition and evaluation. Although embolic etiologies predominate, low-flow ischemia related to hemodynamic instability represents an underrecognized mechanism. We report the case of a 66-year-old woman with end-stage renal disease (ESRD) on hemodialysis who experienced recurrent transient right-eye visual symptoms near the end of dialysis sessions. She had chronic intradialytic hypotension, with systolic blood pressures ranging from 90 to 100 mmHg and post-dialysis pressures averaging 90/50 mmHg. Ophthalmologic examination demonstrated markedly reduced visual acuity in the right eye, normal intraocular pressures, full extraocular movements, and full confrontation visual fields bilaterally. Dilated fundus examination showed diffuse retinal pallor with a characteristic cherry-red spot, consistent with CRAO. Comprehensive evaluation, including carotid Doppler ultrasound, CT angiography of the head and neck, brain magnetic resonance imaging, and transthoracic echocardiography, revealed no embolic or large-vessel source. The event was attributed to recurrent intradialytic systemic hypoperfusion superimposed on impaired microvascular autoregulation from diabetes and cardiovascular disease. Management included antiplatelet therapy and optimization of intradialytic blood pressure, after which no further visual ischemic episodes were reported. This case highlights intradialytic hypotension as a potential nonembolic cause of CRAO in patients undergoing hemodialysis and underscores the importance of early recognition and hemodynamic optimization in this high-risk population.