‘Stone’-blindness

A 15-year-old boy with juvenile rheumatoid arthritis (JRA) and end-stage CKD was referred to us for renal replacement therapy. He was previously under follow-up with a paediatric unit. JRA was diagnosed at the age of 3/2 years when he developed polyarthritis and uveitis. He received steroids, sulphasalazine, non-steroidal anti-inflammatory drugs, calcium supplements (calcium phosphate) and vitamin D. Corneal opacities and redness of eye developed 3 years ago and he underwent many sessions of corneal scrapings in a private ophthalmological unit, but was not evaluated further. On evaluation for growth retardation 2 years ago, he was found to have renal dysfunction. A renal biopsy revealed chronic interstitial nephritis. He was initiated on conservative management for CKD. He was continuing treatment at the private hospital for the eye problem without any significant improvement. He had progressive deterioration in vision, redness and worsening of the opacities which remained refractory to surgical debridement. On clinical examination in our unit, he had greyish white haziness extending across the cornea (Figure 1A). Biochemical values showed an elevated calcium-phosphorous product (110.16 mg2/dl2), renal dysfunction (estimated GFR-6 ml/min/1.73 m2, CKD stage 5) and suppressed serum parathyroid hormone (23.8 pg/ml).