We present a case of acute angle closure due to spontaneous suprachoroidal haemorrhage secondary to loss of anti-coagulation control.
A 67-year-old man, who recently returned from a holiday abroad, presented with a one-day history of worsening right visual acuity and 4 day history of increasing right retro-bulbar pain not relieved with simple analgesia.
He had a past medical history of essential tremor managed with Propranolol, Atrial Fibrillation on anticoagulation with Warfarin 4 mg daily – target International Normalised Ratio (INR) 2.5. Possible confusion with his tablets in the week leading up to the start of his symptoms.
Our patient was also known to have normal tension glaucoma (NTG) managed with Latanoprost. He had Selective Laser Trabeculoplasty (SLT) to the right eye 12 months before to improve his intraocular pressure control. His last recorded visual acuity (VA) was 6/6 in both eyes.
On examination the patient was found to have reduced VA in the right eye 6/12 with an injected conjunctiva, cloudy cornea and a mid-dilated pupil with a very shallow anterior chamber (AC) and closed irido-corneal angle on gonioscopy (Figs. 1 and 2). Fundus exam revealed a large supero-nasal suprachoroidal haemorrhage not involving the macula. His right intra-ocular pressure (IOP) was 42 mmHg. The left eye had a VA of 6/6 with a deep AC and IOP of 12 mmHg (Fig. 3). He was therefore diagnosed with acute angle closure secondary to spontaneous suprachoroidal haemorrhage. His INR measured at > 8. The patient was given 1 mg of Vitamin K to reverse his INR, which quickly came down to 5.1. Advice was taken from the general physicians’ team and no further Vitamin K doses were given.
He was started on maximal topical and systemic IOP lowering treatment including G. Apraclonidine 1% TDS, G. Latanoprost 0.005% ON, G. Brinzolamide/Timolol (Azarga®) and Oral Acetaolamide 250 mg QDS as well as cycloplegia with G. Atropine 1% OD.
After 12 h the IOP was 27 mmHg and INR 3.1. But unfortunately, in the following 12 h, the patient had a second bleed, and his IOP went up to 42 mmHg and VA was down to finger counting. There was no view of the fundus due to corneal edema. B-Scan Ultrasound showed an extension of the suprachoroidal haemorrhage, covering 360 degrees and involving the fovea (Fig. 4).
For the next 7 days the patient’s remained on the same medical treatment and his IOP was stable in the high 20s. A decision was taken to perform a combined phacoemulsification and lens implant, pars-plana vitrectomy and suprachoroidal haematoma drainage under general anesthesia. (Additional file 1).
Additional file 1: Video of the combined phacoemulsification and lens implant, pars-plana vitrectomy and suprachoroidal haematoma drainage. (AVI 16420 kb)
Six weeks post operatively the patient had a wide-open angle with a central IOL and a flat retina (Figs. 5 and 6). Intraocular Pressure without IOP lowering treatment was recorded at 20 mmHg with VA 6/24. He was restarted on IOP lowering topical treatment (G Brinzolamide/Timolol BD).