Unilateral Proptosis and Raised Intraocular Pressure Due to Brachiocephalic Vein Stenosis in a Hemodialysis Patient

Background: Central venous stenosis is a known complication in hemodialysis patients, but its association with sight-threatening complications is rare. Case Presentation: A 56-year-old female on hemodialysis presented with progressive binocular diplopia and features of episcleral venous hypertension. On examination she had proptosis, corkscrew vessels, raised Intraocular Pressure (IOP) (30 mmHg) and limitation in elevation and adduction of the left eye. Her Best-Corrected Visual Acuity (BCVA) was 20/30+2 in the right and 20/100-1 in the left. Initial cerebral angiogram was negative for carotid-cavernous fistula. Further questioning revealed she underwent a left brachiocephalic Arteriovenous Fistula (AVF) creation 3 years prior, requiring 3 fistuloplasties due to AVF stenosis. Vascular Surgery was consulted and a Central Venography and left arm Fistulogram was performed, showing a focal occlusion of the left brachiocephalic vein with extensive reflux into the collateral venous channels. This was treated with angioplasty and stenting of the brachiocephalic vein. Outcome: Within 2 days of intervention, proptosis resolved and IOP reduced to 20 mmHg, with further normalization to 15 mmHg at 3-month follow-up, with improved BCVA (20/30) and full ocular motility of the left eye. Discontinuation of IOP-lowering medications and lubricants was possible. Conclusion: This rare case highlights the importance of recognizing central venous stenosis as a potential cause of sight-threatening complications in hemodialysis patients. Early recognition and timely intervention can result in favorable visual outcomes.