Interesting finding in Nephrology practice

1. Interesting finding in Nephrology practice Dr Ravi TejMadipalli Nephrology Resident NIMS, Hyderabad

2. Case scenario • A 25 year male patient • CKD since October 2018 on medical management • NKD - IgA nephropathy • Initiated on MHD since June 2019 • MHD 3 times /week • Present access via left RCF

3. On routine OPD visit he presented with • Redness and irritation of eyes since 2 week A/W • Nausea, vomiting , headache & abdominal pain • Photophobia • No visual abnormality

5. Differential diagnosis of red eye • Glaucoma • Hyphaema • Hypopyon • Iritis • Keratitis/ Scleritis/ Conjunctivitis • Stye/ Chalazion/ Blepharitis • Corneal abration • Foreign body • Episcleritis • Dry eye syndrome

6. Ophthalmology opinion: ruled out all local causes of red eye.

7. On evaluation, • Serum Calcium - 11.9mg/dl • Serum Phophorus – 6.6 mg/dl • 25 hydroxy Vitamin D - >150ng/ml • iPTH levels – 6.9 pg/ml • S.ALP- 91

8. Patient received 2 sessions of calcium free Haemodialysis and withdrawal of Vitamin D supplements • Serum calcium – 8.8 mg/dl • Serum phosphorus – 6.2 mg/dl • He had symptomatic relief with resolution of his red eye

9. Post HD his eye findings

10. In view of brisk response to hypercalcemia management, his red eye was attributed to Hypercalcemia secondary to Vitamin D toxicity

11. Discussion • There is literature supporting the occurrence of red eye secondary to Hypercalcemia • Published literature had attributed the cause for hypercalcemia associated red eye to Sarcoidosis , Primary hyperparathyroidism. • Here with, we present a case of red eye with hypercalcemia secondary to Iatrogenic Vitamin D toxicity.

12. A 42-year-old man with sarcoidosis presenting as red eye secondary to hypercalcemia.

13. A 28 year old man presenting as red eye syndrome later found to have primary hyperparathyroidism.