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Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight-heparin
Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular
T. Salvá-Palomeque
, D. Ruiz-Casas, N. Alonso-Formento
Corresponding author
Departamento de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Salvá-Palomeque, D. Ruiz-Casas, N. Alonso-Formento" "autores" => array:3 [ 0 => array:4 [ "nombre" => "T." "apellidos" => "Salvá-Palomeque" "email" => array:1 [ 0 => "tsalvapalomeque@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Ruiz-Casas" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Alonso-Formento" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 517 "Ancho" => 755 "Tamanyo" => 51515 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">2 months after right eye surgery: pigment dispersion and inferior hypopigmentation after choroidal hemorrhage resorption.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Suprachoroidal hemorrhage, blood accumulation within the suprachoroidal space, usually develops as the result of intraocular surgery, ocular trauma or other events leading to sudden ocular hypotony. Spontaneous cases are uncommon and have been reported rarely, usually associated with a poor visual prognosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> Predisposing risk factors for spontaneous suprachoroidal hemorrhage (SSCH) include advanced age, atherosclerosis, vascular disease, arterial hypertension, anticoagulation therapy, chronic kidney disease, aphakia, age-related macular degeneration (ARMD) and glaucoma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of bilateral SSCH in a patient taking sodium enoxaparin, a low-molecular-weight heparin, who had no other known ocular condition predisposing to choroidal bleeding. Despite the widespread use of anticoagulation therapy, sight-threatening ocular complications associated with such therapy not related to surgical procedures remain extremely rare. Previously reported complications of anticoagulation include vitreous and massive subretinal haemorrhages in patients with ARMD, hyphema, orbital haemorrhages and unilateral SSCH.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">An 81-year-old woman came into the Emergency department complaining of pain, subconjunctival swelling and vision loss in her right eye during the previous five days. She had no recent history of eye surgery or trauma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Her medical conditions included high blood pressure, dyslipidemia, chronic atrial fibrillation and valvulopathy, which had required an aortic valve exchange seven months earlier. After cardiac surgery she had been treated with acenocumarol but due to a hip fracture, this had been switched to low molecular weight heparin 60 mg /12 h two weeks before her visit to Emergency.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ophthalmological examination showed a hyporeactive pupil, mild conjunctival hyperemia, marked serohemorrhagic chemosis, an edematous cornea and a shallow anterior chamber with an anteriorly displaced iris-intraocular lens complex in her right eye. She had a mild proptosis but ocular movements were not limited. Intraocular pressure (IOP) was 32 mmHg and visual acuity was counting fingers. Right eye fundoscopy revealed an extensive hemorrhagic choroidal detachment involving the inferior choroid associated with exudative retinal detachment. Ocular posterior segment ultrasonography (US) examination showed a massive inferior choroidal detachment with an overlying retinal detachment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An orbit computed tomography (CT) scan confirmed the presence of suprachoroidal blood, with no associated orbital pathology. Visual acuity in the left eye was 20/20 and anterior chamber and fundus examination were unremarkable. A blood test did not find abnormal coagulation parameters.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment was started with hypotensive eye drops (Brinzolamide 10 mg/mL twice daily) and lubricant ointments (Oxytetracycline and hydrocortisone 10/30 mg/g thrice daily). Two days later she presented mild visual loss in her left eye (20/40), with a small choroidal hemorrhagic detachment without macular involvement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Vision had dropped to light perception in her right eye and US evidenced choroidal detachment progression, although there was no contact between the choroidal detachments.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The case was discussed with the Hematology Department, and anticoagulant treatment was stopped due to the presence of active bleeding. During the next two weeks, the choroidal detachment of the left eye resolved completely and there was an improvement in the right eye. The patient's hematologist decided to re-start treatment given the high thrombotic risk of the patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Three months later vision had improved to 20/20 in the left eye and the choroidal hemorrhage and associated exudative retinal detachment had resolved completely in the right eye. However, visual acuity was counting fingers due to persistent blood in the vitreous. A pars plana vitrectomy with air tamponade was successfully performed in right eye (see Video, Supplemental Digital Content 1). Although there was some peripheral inferior subretinal scarring due to blood reabsorption, visual acuity improved to 20/50 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">SSCH is a rare condition with a poor visual prognosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–6</span></a> There are only few reports of SSCH development in patients with no predisposing ocular conditions, none of them with bilateral involvement.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is uncertain whether the anticoagulation therapy <span class="elsevierStyleItalic">per se</span> was the primary cause of SSCH in our patient; we believe our patient may have had underlying choroidal abnormalities related to her age and vascular disease.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Anticoagulation therapy with low molecular weight heparin is increasingly employed in clinical practice. It has a more favorable antithrombotic-to-hemorrhage ratio, a higher bioavailability, longer half-life and a more predictable anticoagulation response to weight-adjusted dose, when compared to standard heparin. These characteristics make the administration of low molecular weight heparin more comfortable (an injection once or twice a day without the need for laboratory blood monitoring), therefore providing an impetus for a shift from standard heparin therapy to low molecular weight heparin therapy.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Low molecular weight heparin does not modify coagulation parameters, so it cannot be monitored analytically. In our patient anticoagulation was mandatory given the great thrombophilic risk of a mechanical valve, atrial fibrillation and hip fracture. Therefore, once active ocular bleeding stopped, the drug was restarted, with close monitoring by the Hematology department.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Temporary suspension of anticoagulant treatment, with topical treatment to control ocular hypertension led to the resolution of the choroidal detachments. Vitrectomy was performed to clear the vitreous hemorrhage, leading to improvement of visual acuity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In summary, we report a case of SSCH without predisposing ocular factors related to anticoagulant treatment, with bilateral, simultaneous involvement which resolved favourably.</p></span><span id="sec1015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1041">Conflict of interests</span><p id="par1061" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This article has no funding source.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1600811" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1434534" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1600812" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1434533" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec1015" "titulo" => "Conflict of interests" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-16" "fechaAceptado" => "2020-11-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1434534" "palabras" => array:3 [ 0 => "Hemorrhagic choroidal detachment" 1 => "Low-molecular-weight heparin" 2 => "Spontaneous suprachoroidal hemorrhage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1434533" "palabras" => array:3 [ 0 => "Desprendimiento coroideo hemorrágico" 1 => "Heparina de bajo peso molecular" 2 => "Hemorragia supracoroidea espontánea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">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.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">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.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">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 tres 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.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">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.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Salvá-Palomeque T, Ruiz-Casas D, Alonso-Formento N. Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular. Arch Soc Esp Oftalmol. 2021;96:615–617.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 579 "Ancho" => 755 "Tamanyo" => 77561 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">B-scan reveals suprachoroidal hemorrhage with an overlying retinal detachment.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 505 "Ancho" => 755 "Tamanyo" => 44009 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Wide field retinography showing a small hemorrhagic choroidal detachment in the left eye.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 517 "Ancho" => 755 "Tamanyo" => 51515 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">2 months after right eye surgery: pigment dispersion and inferior hypopigmentation after choroidal hemorrhage resorption.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 25939719 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous suprachoroidal hemorrhage associated with iatrogenic coagulopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F.S. 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