Abstract
Purpose
To describe a case of massive spontaneous subconjunctival hemorrhage in a patient taking warfarin with a therapeutic international normalized ratio (INR).
Observations
Massive circumferential hemorrhagic chemosis, extensive periorbital and facial ecchymosis, and active arterial extravasation in the subconjunctiva which required cessation and reversal of anticoagulation. Findings gradually resolved over several months after discharge.
Conclusions and importance
While subconjunctival hemorrhage, even in anticoagulated patients, is usually benign, rare examples of severe presentations exist. We present, to our knowledge, the first documented case of a subconjunctival hemorrhage necessitating cessation and reversal of anticoagulation in the setting of a therapeutic INR.
1
Introduction
Subconjunctival hemorrhage (SCH) is a typically benign process characterized by acute, painless bleeding into the subconjunctival space. It is a common ocular condition with risk factors that include hypertension, hyperlipidemia, diabetes mellitus, anticoagulation therapy, and increased age (particularly over 50-years old given the previously mentioned risk factors). While often spontaneous, SCH can be caused by Valsalva maneuvers, ocular and orbital trauma, and potentially serious systemic causes of coagulopathy. Warfarin, the most prescribed outpatient anticoagulant in North America, is a known cause of spontaneous SCH, with an incidence of 0.35–1.56%. ,
While a supratherapeutic international normalized ratio (INR) has not been shown to increase the risk of SCH, patients on warfarin with SCH should have their INR and prothrombin time (PT) checked to evaluate systemic coagulation status. , Warfarin-associated SCH usually resolves spontaneously after 5–10 days and rarely requires more than supportive care. Documented cases of severe warfarin-associated SCH requiring cessation of anticoagulation, cessation and surgical evacuation, or cessation and reversal of supratherapeutic anticoagulation are extremely rare in the literature. Usually, SCH are self-limiting, not overly severe, and do not require intervention. Therefore, formalized guidelines for proper anticoagulation management in warfarin-associated SCH do not exist and clinical judgement usually dictates treatment strategy.
Herein, we present a case that, to our knowledge, is the only reported occurrence of a warfarin-associated SCH in which the severity of presentation necessitated inpatient admission with cessation and reversal of anticoagulation in the setting of a therapeutic INR. This uniquely severe presentation of a condition universally regarded as benign provides the opportunity to examine the current literature regarding warfarin-associated SCH and offer insights to management strategies.
2
Case report
An 86-year-old Caucasian male presented to our institution’s Emergency Department (ED) in May 2020 with progressive swelling and bleeding of his right eye with visual obstruction. His medical history was significant for hypertension, grade III chronic kidney disease, and atrial fibrillation. His ocular history was significant for bilateral cataract extractions with PCIOL implantation in 2013 and bilateral YAG laser capsulotomies in 2013. His medications were significant for Aspirin-CaCO3 81–300 mg daily, metoprolol ER 50 mg daily, and warfarin 2.5 mg daily with two days of 3.75 mg dosing. The rest of his history was non-contributory.
One week prior to presentation, the patient noticed an initially small, but slowly progressive, amount of blood overlying the sclera of his right eye. He eventually experienced slight obstruction of his vision from the blood as well as minor periorbital ecchymosis. Two days prior to presentation, the patient was diagnosed with a small SCH by an outside ophthalmologist and was instructed to discontinue his warfarin and was told to not worry about the bleeding. After two days of progressive bleeding, he presented to an outside hospital ED, where active subconjunctival bleeding and hemorrhagic chemosis were documented. Laboratory evaluation at that time showed an INR of 2.85 with a PT of 32.9. Due to this atypical presentation, the patient was referred to our institution for further management.
On presentation to our ED, the patient denied any pain, dizziness, blurry vision, or history of recent trauma to the eye or face. Of note, the patient was normotensive with a blood pressure of 120/81 mmHg. Best visual acuity sans correction was found to be 20/80 in the right eye and 20/40 in the left eye. Intraocular pressure and pupillary exam were both within normal limits. External examination revealed periorbital ecchymosis with trace edema, massive 360-degree hemorrhagic chemosis, and active bleeding from the subconjunctiva with overflow onto the patient’s face ( Fig. 1 A, B ). Extraocular movements in the right eye were restricted 50% in all quadrants, while there were no restrictions in the left eye. Slit lamp and fundus examinations revealed no further abnormalities.
