A Traumatic Hyphema in a Patient on Anticoagulation
A 71-year-old man on warfarin for atrial fibrillation (INR 2.8, in range) presents 4 hours after being struck in the right eye by a tennis ball. Acuity is counting fingers right and 6/6 left. There is a 3 mm layered hyphema occupying about 30% of the anterior chamber, with no active bleeding visible. Intraocular pressure is 30 mmHg right and 15 mmHg left. There is a small pupil, a brisk afferent defect is not detected, and the view to the fundus is hazy but the red reflex is present. There is a subconjunctival haemorrhage and periorbital swelling. He has no known bleeding disorder and takes no aspirin or NSAIDs. He asks whether he should stop the warfarin and whether he can go home.
1. Prioritise the immediate risks in this eye and explain the reasoning behind each.
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The immediate risks are, in order of urgency:
1. Rebleeding. The commonest cause of a poor outcome. Clot lysis around day 2–5 can produce a fresh, larger bleed with higher pressure and worse prognosis. Risk factors here include the size of the initial bleed and anticoagulation. This drives admission or very close review and activity restriction.
2. Raised intraocular pressure and corneal blood staining. At 30 mmHg with a hyphema, pressure must be controlled to protect the optic nerve and to prevent blood products entering the cornea, which is more likely with prolonged elevation and a large clot. Sickle cell status matters because of the risk of central retinal artery occlusion at lower pressures; this patient is older but haemoglobinopathy should still be considered if pressure rises.
3. Posterior segment injury. The mechanism - a blunt projectile - raises the possibility of commotio retinae, retinal dialysis, choroidal rupture, or a concealed globe rupture. The hazy view means a dilated fundus examination and B-scan should be arranged once safe, and a CT orbit should be considered if there is any suspicion of rupture, orbital fracture, or intraocular foreign body.
4. Anticoagulation dilemma. Stopping warfarin risks stroke; continuing it risks rebleeding. This is a joint decision with the physician or cardiologist, not a unilateral ophthalmic one.
5. Missed open globe. A small pupil and hazy view could mask a wound; check for peaked pupil, shallow anterior chamber, hypotony, and Seidel.
2. Justify a management plan, including the anticoagulation question and disposition.
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Anticoagulation. Do not stop warfarin unilaterally. The INR is therapeutic and the stroke risk from interruption is real. Contact the treating physician the same day to discuss. In many cases the safest course is to continue anticoagulation with close monitoring, since evidence that reversal improves ocular outcome is weak and the systemic risk is significant. If the eye deteriorates with uncontrolled pressure or rebleeding, reversal can be reconsidered jointly. Avoid aspirin and NSAIDs for analgesia; use paracetamol.
Intraocular pressure. Treat the 30 mmHg. Topical beta-blocker and topical alpha-agonist are reasonable first-line. Avoid topical prostaglandin analogues, which are associated with inflammation. Avoid systemic carbonic anhydrase inhibitors if there is any concern about sickle cell trait, and use them cautiously in an older patient with cardiac risk. If pressure remains above about 35–40 mmHg despite medical therapy, or if there is corneal blood staining, consider anterior chamber washout.
Activity and local measures. Admit or arrange daily review for the first few days given the rebleed risk. Bed rest with head elevation, shield, no straining, avoid Valsalva, treat cough and constipation. Do not patch the eye in a way that prevents monitoring. Topical steroid and cycloplegic to reduce inflammation and ciliary spasm.
Monitoring. Check acuity, pressure, and hyphema size at least daily initially. Gonioscopy after the clot resolves to look for angle recession. Dilated fundus examination and B-scan when the view permits. Review at 1 week, 1 month, and 3 months for pressure rise from angle recession, which can present late.
Disposition. Given the anticoagulation, the pressure, and the need for daily review, admission or a same-day ophthalmology unit review is appropriate rather than discharge home. Document the discussion with the physician and the patient about the anticoagulation decision.