29-year-old woman diagnosed with CKD secondary to FSGS. She was admitted for haemodialysis at the age of 25. Three years after haemodialysis she presented severe secondary hyperparathyroidism (SHPT) with iPTH >1,000 pg/ml, bone pain, asthenia, pruritus and persistent symptomatic arterial hypotension. There were no arterial or echocardiographic calcifications. Parathyroid ultrasound was performed without visualisation and scintigraphy with 99Tc and MIBI with diffuse increase in the fixation of the left and right inferior parathyroid lobe. He underwent treatment of his STPP with calcium chelators and discontinued i.v. calcitriol due to hyperphosphataemia. Subtotal parathyroidectomy was indicated considering the patient's age and her suitability for transplantation. The results of the previous laboratory tests were: Hcto 37%, Hb 12.1, Ca 9 mg/dl, P 6 mg/dl, K 5 meq/l. Coagulogram normal. Parathyroid biopsy: bilateral hyperplasia. During surgery she was hypotensive (average BP 90/60). Six days after surgery she had partial loss of vision in the left ventricle and total loss of vision in the right ventricle, moderate hypo-Ca and symptomatic hypotension. Laboratory: Hcto 36%, Hb 12, Ca 6.3 Ca i 0.72l, P 3.5, Mg 1.9. Hypo-Ca values are corrected.
Normal collagenogram and coagulogram, and anticardiolipins, lupus anticoagulant, ANCAp and c and serology for toxoplasmosis and syphilis negative.
Consultation with neurology: he presented with right nasal haemianopsia and bulging vision in the left eye. Dyscoric pupils in OD 3 mm, OI 4 mm. Consultation with ophthalmology: VA with vision counting fingers at 50 cm in the left eye and moderate visual impairment in the right eye. Areactive mydriasis in the left eye, reactive in the right eye. Fundus: retina applied, normal macula and congestive papilla with incipient oedema (OI and D). PO 10/10 mmHg. Normal brain and bulb MRI. Visual evoked potentials in OD and OI of medium amplitude and prolonged central latencies compatible with moderate compromise of the optic pathway, compatible with optic neuropathy. Visual acuity: 0.5 in the left eye, 0.8 in the right eye. Campimetry: outside normal limits for OD with alteration of relative sensitivity and restriction of the blind spot (increased). In OI there is a total reduction in sensitivity.
Corticosteroids (prednisone) at a dose of 1 mg/kg/day for 30 days were prescribed as treatment.
The patient progresses with increased papillary oedema in both eyes and clinically with bulging vision in the OD and amaurosis of the OI.
Fundus examination at 2 months showed almost total atrophy of the right optic nerve with dilatation and venous tortuosity and total atrophy of the left optic nerve.

