Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight-heparin.

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye. Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome.

Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular / Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight heparin

Presentamos el caso de una paciente de 81 años en tratamiento con enoxaparina sódica, que desarrolló una hemorragia supracoroidea espontánea bilateral. Tras suspender el tratamiento anticoagulante se produjo una mejoría clínica, que se mantuvo incluso tras reiniciar la anticoagulación. Tras 3 meses de seguimiento, la hemorragia coroidea se resolvió completamente en ambos ojos, pero se decidió realizar una vitrectomía pars plana en el ojo derecho de la paciente, el más afectado inicialmente, debido a un hemovítreo persistente. La agudeza visual alcanzada fue de 20/50 en el ojo derecho y 20/20 en el ojo izquierdo. La hemorragia supracoroidea es una entidad poco frecuente, asociada habitualmente a un mal pronóstico visual. Se han descrito pocos casos en la literatura de hemorragia supracoroidea en pacientes sin factores de riesgo oculares, ninguno de ellos bilateral. Este podría ser el primer caso descrito en la literatura de hemorragia supracoroidea bilateral simultánea sin factores oculares predisponentes relacionado con anticoagulantes, resuelto con un buen resultado visual (AU)

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye. Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome (AU)

SPONTANEOUS SUPRACHOROIDAL HEMORRHAGE ASSOCIATED WITH IATROGENIC COAGULOPATHY.

PURPOSE: To present a case of spontaneous suprachoroidal hemorrhage in a patient on anticoagulation. METHODS: Single case report. RESULTS: A 68-year-old woman with a history of hypertension, atherosclerosis, and heart failure presented with massive spontaneous suprachoroidal hemorrhage in the left eye. She had no known ophthalmic pathology. She was taking warfarin and she had a high international normalization ratio. Despite medical and surgical therapy, there was no improvement and vision deteriorated to no light perception. CONCLUSION: Spontaneous expulsive suprachoroidal hemorrhage is a rare entity. Advanced age, systemic anticoagulation, and hypertension are strong risk factors. It is important to monitor international normalization ratio in warfarinized patients; particularly, uncontrolled high levels may cause spontaneous suprachoroidal hemorrhage in the absence of predisposing ocular pathology.

[Spontaneous choroidal hemorrhage associated with novel oral anticoagulants: A report of two cases and literature review]. / Hémorragie choroïdienne spontanée associée à la prise de nouveaux anticoagulants oraux : cas cliniques et revue de la littérature.

New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.

Spontaneous choroidal hemorrhage in a patient on dabigatran etexilate (Pradaxa).

PURPOSE: To report the first known case of spontaneous choroidals in association with a patient on dabigatran etexilate. METHODS: Observational case report. RESULTS: An 82-year-old man on 150 mg dabigatran etexilate by mouth twice a day for atrial fibrillation developed spontaneous choroidal hemorrhage in his left eye. No other causes were found after careful history and examination. CONCLUSION: Dabigatran is a popular new alternative to warfarin that has no blood monitoring or reversal agent. Physicians should be aware of this new medication and its possible hemorrhagic complications.

Hemorrhagic choroidal detachment after use of anti-glaucomatous eye drops: case report.

Eighty-two-year-old patient with a pacemaker using warfarin due to arrhythmia and having an intraocular lens in the right eye, developed spontaneous hemorrhagic choroidal detachment one day after the use of combined preparation of 0.5% timolol maleate and 0.004% travoprost, due to primary open-angle glaucoma. Hemorrhagic detachment was detected by anterior and posterior segment examination, as well as B-scan ultrasonography. After the detachment, excessive increased intraocular pressure was controlled with oral carbonic anhydrase inhibitor, cycloplegic and steroid therapy. After four months, visual acuity was 20/20 and the intraocular pressure was under control with 0.5% timolol maleate and 1% brinzolamide. Controlled reduction of the intraocular pressure should be considered, particularly in older patients under anticoagulant therapy and that had undergone prior ocular surgery.

Hemorrhagic choroidal detachment after use of anti-glaucomatous eye drops: case report / Descolamento hemorrágico de coroide após o uso de colírios antiglaucomatosos: relato de caso

Eighty-two-year-old patient with a pacemaker using warfarin due to arrhythmia and having an intraocular lens in the right eye, developed spontaneous hemorrhagic choroidal detachment one day after the use of combined preparation of 0.5% timolol maleate and 0.004% travoprost, due to primary open-angle glaucoma. Hemorrhagic detachment was detected by anterior and posterior segment examination, as well as B-scan ultrasonography. After the detachment, excessive increased intraocular pressure was controlled with oral carbonic anhydrase inhibitor, cycloplegic and steroid therapy. After four months, visual acuity was 20/20 and the intraocular pressure was under control with 0.5% timolol maleate and 1% brinzolamide. Controlled reduction of the intraocular pressure should be considered, particularly in older patients under anticoagulant therapy and that had undergone prior ocular surgery.

Paciente de oitenta e dois anos de idade com marca-passo e utilizando varfarina devido à arritmia cardíaca e com uma lente intraocular no olho direito, desenvolveu descolamento de hemorrágico espontâneo de coroide um dia após o uso de colírio combinado de maleato de timolol a 0,5% e travoprosta a 0,004%, devido ao glaucoma de ângulo aberto primário. O descolamento hemorrágico foi detectado por análise do segmento anterior e posterior, bem como ultrassonografia modo B. Após o descolamento, o aumento excessivo da pressão intraocular foi controlado por inibidor da anidrase carbônica via oral, terapia cicloplégica e esteroides. Após quatro meses, a acuidade visual era 20/20 e a pressão intraocular estava sob controle com o maleato de timolol a 0,5% e brinzolamida a 1%. A redução controlada da pressão intraocular deve ser considerada, especialmente em pacientes idosos sob terapia anticoagulante e que tinham sido submetidos à cirurgia ocular prévia.

Postoperative suprachoroidal hemorrhage in a glaucoma patient on low molecular weight heparin.

Suprachoroidal hemorrhage is a complication associated with intraocular surgery that can occur both intraoperatively and postoperatively. Several intraoperative or postoperative risk factors have been identified. The use of low-molecular weight heparin (LMWH) is considered one of the risk factors in surgical cases (ocular or non ocular) and non-surgical cases. Here we present a case of suprachoroidal hemorrhage in a glaucoma patient that occurred after preoperative prophylactic LMWH for deep venous thrombosis. The use of LMWH has been reported to cause suprachoroidal hemorrhage even in patients without any risk factors. The use of LMWH continues to increase, hence it is important to be aware of the possibility of suprachoroidal hemorrhage and to determine the risk/benefit ratio, especially in patients with other risk factors.

Maintenance of perioperative antiplatelet and anticoagulant therapy for vitreoretinal surgery.

BACKGROUND: The objective of this study was to prospectively assess the risk of bleeding from vitreoretinal surgery in a continuous unbiased cohort of patients taking unsuspended antiplatelet or anticoagulant therapy. DESIGN: Prospective hospital-based study. PARTICIPANTS: Eighty-five patients taking unsuspended aspirin, clopidogrel and/or warfarin therapy undergoing all forms of vitreoretinal surgery at The Mater Misericordiae University and The Mater Private Hospital, Dublin, Ireland. METHODS: Consecutive patients undergoing vitreoretinal surgery taking unsuspended antiplatelet or anticoagulant therapy over a 1-year period were included in this prospective study to evaluate the intraoperative and postoperative bleeding complications. MAIN OUTCOME MEASURES: The intraoperative and postoperative bleeding rates. RESULTS: One hundred and seven vitreoretinal procedures were performed on 85 patients taking unsuspended antiplatelet or anticoagulant therapy. The intraoperative bleeding rate was 23%, the majority of which consisted of mild bleeding into the vitreous cavity during vitrectomy. The postoperative bleeding rate was 22%, consisting of 3.7% anterior chamber haemorrhage, 11% dispersed vitreous cavity haemorrhage, 4.7% dense vitreous cavity haemorrhage, 0.9% subretinal haemorrhage and 1.9% localized choroidal haemorrhage. The single greatest significant independent predictor of intraoperative bleeding was proliferative diabetic retinopathy and of postoperative bleeding was the presence of diabetes mellitus. CONCLUSIONS: There were no cases of uncontrolled intraoperative haemorrhage or serious postoperative choroidal haemorrhage. Mild haemorrhagic oozing during vitrectomy and dispersed vitreous cavity haemorrhage postoperatively were common. For the majority of patients taking antiplatelet or anticoagulant medication, these agents can be safely continued in the vitreoretinal surgical perioperative period.

Acute suprachoroidal haemorrhage post-tenecteplase thrombolysis for myocardial infarction: management considerations.

We report a case of a 63-year-old man who received intravenous tenecteplase as thrombolytic therapy for an inferior ST elevation myocardial infarction. Three hours later he complained of blurred vision in the right eye and on examination had sustained a suprachoroidal haemorrhage. With conservative treatment the haemorrhage resolved, leading to a normalisation of visual acuity. To the authors' knowledge, no case reports exist of this rare complication following intravenous tenecteplase. We discuss implications for further thrombolysis and anticoagulation.

[Spontaneous subretinal isolated hematomas or associated with macular degeneration: a retrospective review of 95 cases]. / Diagnostic des hématomes sous-rétiniens spontanés isolés ou associés à une dégénérescence maculaire liée à l'âge. Etude rétrospective de 95 cas.

INTRODUCTION: Diagnosis of choroidal hematoma, either spontaneous or associated with age-related macular degeneration, is clinical. In some cases of expansive or posterior lesion, hematoma may be misdiagnosed as a tumor. MRI and color Doppler imaging (CDI) are important in ruling out uveal melanoma in these cases. PATIENTS AND METHODS: We reviewed the clinical, MRI, and ultrasonographic characteristics of 95 patients sent to the Curie Institute for suspected uveal melanoma between 1998 and 2006, whose final diagnosis was a choroidal hematoma. Imaging differences with melanomas are discussed. RESULTS: A total of 95 patients with a diagnosis of hematoma were seen; the age varied from 54 to 92 years with a median age of 77 years; there was a history of macular degeneration in 27 cases and 11 patients were taking an anticoagulant. Intravitreous hemorrhage was noted in 18 cases and the lesion was located in the posterior pole in 28 cases. The thickness of the lesions measured by B scan ultrasonography varied between 1 and 7.8mm, with a mean thickness of 2.86mm. MRI was performed in 27 cases and CDI in ten cases. On CDI, hematomas appeared as linear or regular bulging lesions with no intralesional blood flow. On MRI, hematomas appeared as a high-intensity signal on T1-weighted images, heterogeneous on T2-weigted images in relation to the progression of the clot, but no contrast enhancement was noted inside the lesion. Follow-up examinations showed the progressive involvement of the clot and delayed decreasing size of the lesion. CONCLUSION: The diagnosis of choroidal hematoma is usually made by fundus examination. In some posterior locations with pseudo-tumoral appearance, CDI and MRI are useful to rule out a uveal tumor.

Massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with Plavix.

PURPOSE: To report a case of massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with clopidogrel bisulfate (Plavix). METHODS: Case report. RESULTS: A 75-year-old man presented with pain and loss of vision in the left eye for 1 week. His medical history was remarkable for systemic hypertension, chronic renal failure, and artery coronary disease. For 6 months, he had been taking 75 mg/day of Plavix after coronary angioplasty. Ocular examination revealed the patient to be in angle closure. Ultrasonography and computed tomography scan revealed a massive choroidal hemorrhage pushing the iris-lens diaphragm forward. Pain and intraocular pressure were treated successfully with evacuative sclerotomies, but the final exitus after 6 months was bulbar phthisis. CONCLUSIONS: Massive spontaneous choroidal hemorrhage is an extremely rare event that usually has been described in older patients (65-87 years old) receiving anticoagulants or thrombolytic agents. Systemic hypertension, generalized atherosclerosis, and age-related macular degeneration are additional risk factors. In the present case, massive choroidal hemorrhage was associated with use of clopidogrel bisulfate (Plavix) in a patient with chronic renal failure. Our report indicates that Plavix should be administered with caution in patients with chronic renal failure owing to the risk of serious choroidal bleeding. Chronic renal failure should be also included in the list of risk factors for massive spontaneous choroidal hemorrhage. Evacuative sclerotomies may have value in the relief of pain and elevated intraocular pressure but has not been shown to be beneficial in visual and anatomic outcomes.

The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications.

AIMS: This study aims to establish the prevalence of aspirin, dipyridamole, clopidogrel, and warfarin use in patients undergoing cataract surgery, and to compare local anaesthetic and intraoperative complication rates between users and non-users. METHODS: The Cataract National Dataset was remotely extracted and anonymised on 55,567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006. RESULTS: This report analyses 48,862 of the 55,567 operations from the eight centres, which routinely recorded a drug history. In all, 28.1% of the 48,862 patients were taking aspirin, 5.1% warfarin, 1.9% clopidogrel, and 1.0% dipyridamole. The recording of any complication of a sharp needle or subtenon's cannula local anaesthetic block was increased in patients taking clopidogrel, 8.0% (P<0.0001) or warfarin, 6.2% (P=0.0026) vs non-users, 4.3%, but no increase in potentially sight-threatening complications was identified. The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel, 4.4% (P<0.0001) or warfarin, 3.7% (P<0.0001) vs non-users, 1.7%. The recording of any operative complication was increased in those taking clopidogrel, 7.3% (P=0.0002) vs non-users, 4.4%, but the haemorrhagic operative complications of choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased. The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel, 3.23% (P=0.0057) vs non-users, 1.77%. CONCLUSIONS: Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenon's cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications.