Abstract
Background: Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior
chamber of the eye without a predisposing traumatic event. Hyphema can be associated
with acute elevations in intraocular pressure in up to 30% of cases, which poses a
significant risk for permanent vision loss if not quickly recognized and treated in
the emergency department (ED). Anticoagulant and antiplatelet medications have been
previously associated with cases of spontaneous hyphema; however, there are limited
reports of hyphema with associated acute glaucoma in a patient taking a direct oral
anticoagulant. Due to the limited data of reversal therapies for direct oral anticoagulants
in intraocular hemorrhage, these patients pose a challenge in deciding whether to
reverse anticoagulation in the ED.
Case Report: We present a case of a 79-year-old man on apixaban anticoagulation therapy
who presented to the ED with spontaneous painful vision loss in the right eye with
associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage,
and tonometry was significant for acute glaucoma. As a result, the decision was made
to reverse the patient's anticoagulation with four-factor activated prothrombin complex
concentrate.
Why Should an Emergency Physician Be Aware of This? This case is an example of acute
secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence
regarding anticoagulation reversal in this setting. A second site of bleeding was
identified by utilization of point-of-care ultrasound, which led to the diagnosis
of a vitreous hemorrhage. This allowed for shared decision-making between the emergency
medicine physician, ophthalmologist, and patient regarding the risks and potential
benefits of the reversal of anticoagulation. Ultimately, the patient decided to have
his anticoagulation reversed to try and preserve vision.
Keywords
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REFERENCES
- Traumatic hyphema.Int Ophthalmol Clin. 2002; 42: 57-68
- Controversies in the pathophysiology and management of hyphema.Surv Ophthalmol. 2016; 61: 297-308
- Management of traumatic hyphema.Surv Ophthalmol. 2002; 47: 297-334
- Risk of intraocular hemorrhage with new oral anticoagulants.Eye (Lond). 2017; 31: 628-631
- US emergency department visits for outpatient adverse drug events, 2013–2014.JAMA. 2016; 316: 2115-2125
- Bilateral spontaneous hyphema, vitreous hemorrhage, and choroidal detachment with concurrent dabigatran etexilate therapy.Ophthalmic Surg Lasers Imaging Retina. 2016; 47: 78-80
- Spontaneous hyphaema in a patient on warfarin treatment.Br J Clin Pharmacol. 2008; 66: 414-415
- Subconjunctival hemorrhage in a patient on dabigatran (Pradaxa).Am J Emerg Med. 2013; 31: e3-e5
- Ophthalmic complications associated with direct oral anticoagulant medications.Semin Ophthalmol. 2017; 32: 614-619
- Risk of substantial intraocular bleeding with novel oral anticoagulants: systematic review and meta-analysis.JAMA Ophthalmol. 2015; 133: 834-839
- Risk of intraocular bleeding with novel oral anticoagulants compared with warfarin.JAMA Ophthalmol. 2017; 135: 864-870
- Reversal of direct oral anticoagulants: guidance from the anticoagulation forum.Am J Hematol. 2019; 94: 697-709
Article info
Publication history
Published online: December 22, 2022
Accepted:
December 13,
2022
Received in revised form:
November 10,
2022
Received:
September 1,
2022
Publication stage
In Press Uncorrected ProofIdentification
Copyright
© 2022 Elsevier Inc. All rights reserved.
