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ABSTRACT
Objective: To describe the clinical features and management of six patients with ocular complications associated with direct oral anticoagulants (DOACs). Methods: The medical records of all adult patients known to be taking a DOAC and with an unusual bleeding event at a large tertiary referral center over a one-year period were reviewed. Patients with less than one-month follow-up were excluded. Data collection included relevant clinic notes, operative reports, surgical videos, and clinical images (fundus photography, optical coherence tomography, B-scan ultrasonography, and fluorescein angiography). Results: Six eyes in six patients were identified with an unusual bleeding event associated with DOAC use. One patient was taking apixaban, two patients were taking dabigatran, and three patients were taking rivaroxaban. Two patients had large submacular hemorrhage (including one with vitreous hemorrhage breakthrough), three patients had vitreous hemorrhage, and one patient had recurrent hyphema. Presenting visual acuity ranged from 20/40 to light perception. Three individuals required therapeutic and/or diagnostic pars plana vitrectomy for vitreous hemorrhage. Final visual acuity ranged from 20/25 to count finger vision. The associated DOAC was permanently discontinued in two of the six cases. Follow-up was one to four months from onset of identified DOAC-related complication. Conclusions: DOAC use may be associated with ocular bleeding. Ophthalmologists should be aware of potential hemorrhagic complications and obtain consultation with primary providers regarding DOAC cessation guidelines.
ACKNOWLEDGEMENTS
Contributions: Design of study (AC), data collection and analysis (WS, JS, BKH, AS), manuscript preparation (WS, JS, BKH, JIM, EH, AS, ACH, JH, CRD, AC). The authors do not have any proprietary interests in the materials described in the report. Allen Chiang, M.D., has had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
FUNDING
The disclosures for each author include: WS, JS, BKH, ER, AS, AC: None. JIM: Personal fees: Genentech (San Francisco, CA), Regeneron (Tarrytown, NY); advisory board: Genentech (San Francisco, CA). ACH: Personal fees: Alcon (Fort Worth, TX), Allergan (Irvine, CA), Janssen/Johnson & Johnson (New Brunswick, NJ), Genentech (San Francisco, CA), Ophthotech (Princeton, NJ), Regeneron (Tarrytown, NY), Second Sight (Sylmar, CA), Thrombogenics (Leuven, Belgium); grant support: Alcon (Fort Worth, TX), Allergan (Irvine, CA), Avalanche (Menlo Park, CA), Genentech (San Francisco, CA), Janssen/Johnson & Johnson (New Brunswick, NJ), Ophthotech (Princeton, NJ), PanOptica (Bernardsville, NJ), Regeneron (Tarrytown, NY), Second Sight (Sylmar, CA), Thrombogenics (Leuven, Belgium). JH: Personal fees: Xoma (Berkeley, CA), Ophthotech (Princeton, NJ), Optovue (Fremont, CA); Grant support: Ophthotech (Princeton, NJ), Santen (Osaka, Japan). CRD: Personal fees: Allergan (Irvine, CA), Genentech (San Francisco, CA), GlaxoSmithKline (Brentford, UK), Regeneron (Tarrytown, NY), Thrombogenics (Leuven, Belgium); grant support: Allergan (Irvine, CA), Genentech (San Francisco, CA), GlaxoSmithKline (Brentford, UK), Ophthotech (Princeton, NJ), Regeneron (Tarrytown, NY), Thrombogenics (Leuven, Belgium).
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.