Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban

Background: Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior chamber of the eye without a predisposing traumatic event. Hyphema can be associated with acute elevations in intraocular pres-sure in up to 30% of cases, which poses a significant risk for permanent vision loss if not quickly recognized and treated in the emergency department (ED). Anticoagulant and an-tiplatelet medications have been previously associated with cases of spontaneous hyphema; however, there are limited reports of hyphema with associated acute glaucoma in a patient taking a direct oral anticoagulant. Due to the lim-ited data of reversal therapies for direct oral anticoagulants in intraocular hemorrhage, these patients pose a challenge in deciding whether to reverse anticoagulation in the ED. Case Report : We present a case of a 79-year-old man on apixaban anticoagulation therapy who presented to the ED with spontaneous painful vision loss in the right eye with associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage, and tonometry was signifi-cant for acute glaucoma. As a result, the decision was made to reverse the patient's anticoagulation with four-factor ac-tivated prothrombin complex concentrate. Why Should an Emergency Physician Be Aware of This? This case is an example of acute secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence regard-ing anticoagulation reversal in this setting. A second site of bleeding was identified by utilization of point-of-care ultra -sound, which led to the diagnosis of a vitreous hemorrhage. This allowed for shared decision-making between the emer-gency physician, ophthalmologist, and patient regarding the risks and potential benefits of the reversal of anticoagulation. Ultimately, the patient decided to have his anticoagulation reversed to try and preserve vision. (c) 2022 Elsevier Inc. All rights reserved.