Prevalence of ocular hemorrhage in patients receiving warfarin therapy

Ocular Side Effects of Common Systemic Medications and Systemic Side Effects of Ocular Medications

When prescribing medications, it is important to consider the ocular side effects of common systemic therapy as well as potential systemic side effects of ocular medications. Although not an exhaustive list of medications/classes of medications, this article does include many commonly used drugs and also provides information on some topical therapies commonly used by ophthalmologists. These ocular medications may result in systemic effects and/or alter patients' management of systemic conditions.

Massive spontaneous subconjunctival hemorrhage in a patient on therapeutic warfarin: A case report

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.

Update of inflammatory proliferative retinopathy: Ischemia, hypoxia and angiogenesis

Diabetic retinopathy (DR) and retinopathy of prematurity (ROP) present two examples of proliferative retinopathy, characterized by the same stages of progression; ischemia of the retinal vessels, leads to hypoxia and to correct the problem there is the setting up of uncontrolled angiogenesis, which subsequently causes blindness or even detachment of the retina. The difference is the following; that DR initiated by the metabolic complications that are due to hyperglycemia, and ROP is induced by overexposure of the neonatal retina to oxygen. In this review, we will demonstrate the physiopathological mechanism of the two forms of proliferative retinopathy DR and ROP, in particular the role of the CD40/CD40L axis and IL-1 on vascular complications and onset of inflammation of the retina, the implications of their effects on the onset of pathogenic angiogenesis, thus understanding the link between platelets and retinal ischemia. In addition, what are the therapeutic targets that could slow its progression?

Analysis of subconjunctival hemorrhage

Objective: To determine associated conditions, gender distribution and location of subconjunctival hemorrhage (SCH).

Methodology: This retrospective, observational and non-interventional study involved total of 50 patients with SCH aged 0.16-88 years. The conjunctiva was divided into 4 equal areas. The data about the subjects with SCH that includes age, gender, medical history, ocular history and location of hemorrhage were noted for all patients.

Results: The patients with SCH consisted of 21 (42%) women and 29 (58%) men, with a mean age of 29.56 years. Of the 50 patients, 34 (68%) had traumatic and 16 (32%) had spontaneous SCH. Of traumatic SCH group 24 (70.6%) were men and 10 (29.4%) were women. SCH was more common in the temporal areas than other areas (40.5%).

Conclusion: The most associated condition in spontaneous SCH was hypertension. SCH was found to be predominant in the temporal areas among all patients. In traumatic SCH, temporal areas were affected more, whereas in spontaneous SCH, nasal and temporal areas were affected equally. Traumatic etiology was more likely seen in men than women.

Subconjunctival hemorrhage: risk factors and potential indicators

Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted.

Comparison of image-assisted versus traditional fundus examination

BACKGROUND

The purpose of this study was to evaluate the ability of image-assisted fundus examination to detect retinal lesions compared with traditional fundus examination.

METHODS

Subjects were imaged using a nonmydriatic ultrawide field scanning laser ophthalmoscope. After imaging, subjects underwent both a traditional and an image-assisted fundus examination, in random order. During the image-assisted method, ultrawide field scanning laser ophthalmoscopic images were reviewed in conjunction with a dilated fundus examination. Lesions detected by each method were assigned to one of three regions, ie, optic disc, posterior pole/macula, or mid-to-peripheral retina. Discrepancies between the image-assisted and the traditional examination methods were adjudicated by a retinal ophthalmologist.

RESULTS

In total, 170 subjects (339 eyes) were recruited. Agreement between image-assisted and traditional fundus examination varied by lesion type and was excellent for staphyloma (kappa 0.76), fair for suspicious cupping (kappa 0.66), drusen in the posterior pole/macula and mid-to-peripheral retina (0.45, 0.41), retinal pigment epithelial changes in the posterior pole/macula (0.54), peripheral retinal degeneration (0.50), cobblestone (0.69), vitreoretinal interface abnormalities (0.40), and vitreous lesions (0.53). Agreement was poor for hemorrhage in the mid-to-peripheral retina (kappa 0.33), and nevi in the mid-to-peripheral retina (0.34). When the methods disagreed, the results indicated a statistically significant advantage for the image-assisted examination in detecting suspicious cupping (P = 0.04), drusen in the posterior pole/macula and mid-to-peripheral retina (P = 0.004, P < 0.001), retinal pigment epithelial changes in the posterior pole/macula (P = 0.04), nevi in the posterior pole/macula and mid-to-peripheral retina (P = 0.01, P = 0.007), peripheral retinal degeneration (P < 0.001), hemorrhage in the mid-to-peripheral retina (P = 0.01), and vitreous lesions (P < 0.001).

CONCLUSION

Image-assisted fundus examination may enhance detection of retinal lesions compared with traditional fundus examination alone.

Epidemiology of the association between anticoagulants and intraocular hemorrhage in patients with neovascular age-related macular degeneration

PURPOSE

To determine the cumulative incidence and annual incidence of intraocular hemorrhage (subretinal hemorrhage or vitreous hemorrhage) in patients with neovascular age-related macular degeneration (AMD) and association with daily antiplatelet or anticoagulant (AP/AC) medication usage (aspirin, clopidogrel, and warfarin), age, gender, hypertension, diabetes mellitus, or bilateral neovascular AMD.

METHODS

Retrospective cross-sectional study in a tertiary university setting. Data on 195 eyes of 195 patients without previous intraocular hemorrhage examined over 73 months were reviewed.

RESULTS

Ninety-six of 195 patients (49.2%) were taking daily AP/ACs. Of patients taking daily AP/AC agents, 63.5% had hemorrhage compared with 29.2% of patients not taking (odds ratio = 4.21; 95% confidence interval = 1.42-8.46; P < 0.001). The overall annual incidence of intraocular hemorrhage was 0.14% per year. Among patients taking daily AP/AC, the cumulative incidence (61 of 96, 63.5%) and annual incidence (0.10%) of concurrent intraocular hemorrhage were significantly greater compared with patients not taking them (29 of 99, 29.2% and 0.04%, respectively; P < 0.0001). Fourteen of 18 patients (77%) taking more than 1 daily AP/AC had occurrence of intraocular hemorrhage. Antiplatelet or anticoagulant usage was an independent risk factor for the development of intraocular hemorrhage. The use of any agent resulted in a significantly increased risk of developing intraocular hemorrhage. Additionally, presence of bilateral neovascular AMD was a significant association in those taking daily AP/ACs, whereas age was a significant association in those not taking daily AP/AC agents.

CONCLUSION

All three daily AP/AC types were significantly associated with an increased risk of the development intraocular hemorrhage in patients with neovascular AMD, whereas gender, hypertension, and diabetes were not. Age was not significantly associated with hemorrhage in patients taking daily AP/AC agents, whereas the presence of bilateral neovascular AMD was significantly associated with hemorrhage. These findings indicate that the AP/AC use may predispose patients with neovascular AMD to intraocular hemorrhage more so than age and duration of disease alone. While the risk that discontinuing these medicines would pose to the patients' health may be too great to justify, ensuring that an appropriate medication dosage is maintained should be a priority within this patient population.

Contact lens-induced subconjunctival hemorrhage

PURPOSE

To present the first detailed assessment of the clinical features of CL-induced subconjunctival hemorrhage and associated risk factors.

DESIGN

Cross-sectional and case-control study of age-matched randomized groups.

METHODS

A total of 45 CL wearers with subconjunctival hemorrhage aged 18 to 45 years (CL-Hemorrhage group), 200 age-matched healthy control subjects (non-CL group), and 200 age-matched CL wearers (CL group) were enrolled. The conjunctiva was divided into the following 8 equal areas: superior, superior/nasal, nasal, inferior/nasal, inferior, inferior/temporal, temporal, and superior/temporal. The site of hemorrhage, the grade, and other parameters of conjunctivochalasis at 3 locations (nasal, middle, and temporal), and the grade of pinguecula on the nasal or temporal conjunctiva were determined in all subjects.

RESULTS

Typically, subconjunctival hemorrhage affected 1 or 2 regions of the temporal conjunctiva. The grade of conjunctivochalasis and pinguecula was higher in both the affected and unaffected eyes of the CL-Hemorrhage group than the non-CL and CL groups (all P < .00001). The effect of downward gaze or digital pressure on the extent of conjunctivochalasis was more marked in the CL-Hemorrhage group and superficial punctate keratitis was more common (all P < .00001). Multivariate logistic regression analysis of variables revealed that the presence of conjunctivochalasis and pinguecula were associated with an increased risk of CL-induced subconjunctival hemorrhage (all P < .05).

CONCLUSIONS

These results suggest that the major risk factors for CL-induced subconjunctival hemorrhage are conjunctivochalasis and pinguecula.

Effect of systemic medications on onset and progression of diabetic retinopathy

Diabetic retinopathy remains a leading cause of visual loss worldwide. Patients with diabetes mellitus commonly have multiple comorbidities treated with a wide variety of medications. Systemic medications that target glycemic control and coexisting conditions may have beneficial or deleterious effects on the onset or progression of diabetic retinopathy. In addition, data is accumulating to suggest that the use of systemic therapy primarily to address ocular complications of diabetic retinopathy may be a promising therapeutic approach. This article reviews our current understanding of the ocular-specific effects of systemic medications commonly used by patients with diabetes mellitus, including those directed at control of hyperglycemia, dyslipidemia, hypertension, cardiac disease, anemia, inflammation and cancer. Current clinical evidence is strongest for the use of angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers in preventing the onset or slowing the progression of early diabetic retinopathy. To a more limited extent, evidence of a benefit of fibrates for diabetic macular edema exists. Numerous other agents hold considerable promise or potential risk. Thus, these compounds must undergo further rigorous study to determine the actual clinical efficacy and adverse effects before definitive therapeutic care recommendations can be offered.

Risk factors and complications of subconjunctival hemorrhages in patients taking warfarin

OBJECTIVES

The aim of this study was to identify patients with subconjunctival hemorrhage (SCH) on warfarin therapy, to describe risk factors that may contribute to SCH development, and to identify complications related to SCH.

METHODS

A retrospective chart review was conducted including patients treated at a university anticoagulation clinic over 2 years (4,334 patient visits). Data collection included patient demographics; international normalized ratios (INRs) before, at time of, and after SCH; risk factors for increased risk of bleeding; patient-reported complications related to SCH; recent changes in medication use; and warfarin dosage adjustments made in response to the event. The data were summarized using descriptive statistics and frequencies described as percentages.

RESULTS

Fifteen SCH events were identified at an event rate of 0.35%. Two were excluded because of related surgeries near the time of SCH events. The average patient age was 67.3 years (range, 51 to 82). A total of 76.9% (n = 10) of patients had INRs within the goal range at the appointment before reporting the SCH. A total of 46.2% (n = 6) of patients reported alterations in medication regimens during the month preceding SCH. Various patient conditions were documented that may increase the risk of SCH development. No ophthalmic complications were associated with SCHs.

CONCLUSIONS

An SCH event rate of 0.35% was identified. Many factors may have precipitated SCH; however, ophthalmic complications were uncommon.

Ocular bleeding related to warfarin anticoagulation in patients with mechanical heart valve and atrial fibrillation

We investigated the incidence of ocular bleeding in patients taking anticoagulant therapy (warfarin) and its association with other related factors. We examined 210 patients taking warfarin and 210 gender- and age-matched controls for ocular bleeding. Patients and controls were examined by external ocular examination and fundoscopic examination. The incidence of ocular bleeding was 11.4% in patients and 3.8% in controls. It was five times higher in patients with hypertension than in other patients. The incidence of ocular bleeding was higher in older than in younger patients. No association was found between ocular bleeding and factors such as gender, international normalized ratio, duration of warfarin therapy, concomitant aspirin use and diabetes mellitus. Thus, warfarin therapy increases the frequency of ocular bleeding. The higher incidence of ocular bleeding in the patients with hypertension and advanced age should be kept in mind and this subgroup of patients taking warfarin should be monitored closely.

A warfarin-induced subconjunctival hemorrhage

BACKGROUND

Patients who are on warfarin therapy may present with a variety of ocular side effects, particularly hemorrhages. These ocular events may be the only indication that the patient is at risk for serious sequelae, including hemorrhagic stoke.

CASE REPORT

A 76-year-old patient, taking warfarin, presented with a subconjunctival hemorrhage. Four days later the hemorrhage worsened, and the patient developed a headache. Blood testing revealed an elevated International Normalization Ratio (INR) and prothrombin time (PT). The patient's primary care physician adjusted the patient's medication dosage, and the patient's signs and symptoms improved.

CONCLUSIONS

Patients on warfarin therapy who present with ocular bleeding require immediate blood work and consultation with their primary care provider or cardiologist. The optometrist should be aware of the ocular and systemic sequelae of warfarin, its possible drug interactions, and potential controversies regarding cataract surgery in these patients.

An unusual presentation of spontaneous sub-conjunctival haematoma in a patient receiving warfarin

A 65-year-old man on warfarin therapy with a sudden spontaneous onset of sub-conjunctival haematoma associated with bloody tears was assessed in the clinic following a referral from an optometrist. Due to discomfort, diplopia and lagophthalmos, the haematoma necessitated suspension of warfarin therapy and a surgical evacuation. The sub-conjunctival haematoma in a patient receiving warfarin can pose a significant management challenge.

Oral anticoagulant therapy, endocapsular hematoma, and neodymium:YAG capsulotomy

We present a case of endocapsular hematoma, a rare form of intraocular hemorrhage that developed in a patient with pseudophakia receiving oral anticoagulants for previous mitral valve replacement and cerebrovascular disease.

Akutes Winkelblockglaukom nach massiver intraokularer Blutung bei exsudativer altersbedingter Makuladegeneration unter gerinnungshemmender Therapie

BACKGROUND

Acute secondary angle closure glaucoma after massive vitreous and subretinal hemorrhage from exudative age related macular degeneration is a seldom, but devastating complication of an anticoagulative therapy.

PATIENTS

Four patients (age range 70-76 years) developed unilateral acute angle closure glaucoma after massive intraocular bleeding due to exudative age-related macular degeneration and anticoagulative therapy. Three patients received Phenprocomoun and one patient thrombolytic therapy with heparin. One eye had led to blindness at initial investigation. Pars plana vitrectomy was performed in the remaining three eyes. Within a few months, 2 of these 3 eyes were blind, one eye had light perception and all three eyes developed hypotonia.

CONCLUSION

Acute angle closure glaucoma after intraocular bleeding may be the initial clinical manifestation of overtreatment with anticoagulants. Early pars plana vitrectomy probably will increase the surveillance rate of the eye but not the visual prognosis.