Unusual case of dasatinib-associated acute bilateral hyphemas leading to blindness in a patient with chronic myeloid leukaemia.

Chronic myeloid leukaemia (CML) is a myeloproliferative disorder with an incidence of 1-2 cases per 100 000 adults per year.1 Since the International Randomized Study of Interferon and STI571 trial (IRIS trial) in 2003, treatment with tyrosine kinase inhibitors (TKIs) has become the standard of care for patients with newly diagnosed CML in the chronic phase.2 Dasatinib is a second-generation TKI and is generally well tolerated, with cytopenias, gastrointestinal (GI) symptoms and fluid retention being the most commonly observed side effects.3-5 Bleeding complications, although unusual, have been reported with dasatinib, with an incidence ranging from 8% to 24%.3-6 The most commonly reported site of bleeding is the GI tract.3 5 We report an unusual case of dasatinib-associated bleeding presenting with acute bilateral hyphemas, which, to our knowledge, is the first report of its kind.

Three Cases of Spontaneous Hyphaema.

Background Spontaneous anterior chamber bleeding is a rare event. We present three photodocumented cases treated in our clinic. History and Findings Three patients sought medical assistance in our clinic because of bleeding inside the eye and/or visual impairment. None of them had a history of trauma or intraocular surgery. Treatment and Outcome Two patients had oral anticoagulation, which was discontinued. These cases were treated with topical steroids. The third patient had no anticoagulation and no topical steroids were used in treatment. Topical intraocular pressure-lowering drugs were administered as needed. In all three cases, the anterior chamber bleeding stopped spontaneously. No intervention was required. Even after resolution of the bleeding, there were no signs of iris abnormalities. Conclusions In cases of spontaneous anterior chamber bleeding without a history of trauma, oral anticoagulation, hypertension and iris abnormalities such as microaneurysm, pseudoexfoliation, iridocyclitis or neovascularisation have to be considered.

Ophthalmic Complications Associated with Direct Oral Anticoagulant Medications.

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.

Bilateral Spontaneous Hyphema, Vitreous Hemorrhage, and Choroidal Detachment With Concurrent Dabigatran Etexilate Therapy.

A 79-year-old woman was referred for rapid onset of painless bilateral vision loss. Anterior segment exams revealed bilateral spontaneous hyphema and fibrin accumulation. Observation of the posterior chamber by B-scan ultrasound showed vitreous hemorrhage and choroidal detachment bilaterally. No evidence of additional intraocular inflammation was present. Laboratory work-up for hematologic abnormalities was unremarkable. These hemorrhagic events were suspected to be a complication from taking the novel anticoagulant, dabigatran etexilate (Pradaxa; Boehringer, Ingelheim, Germany). She initially underwent non-surgical therapy, which included immediate cessation of dabigatran, and administration of topical and systemic steroids. The lack of response to medical therapy in the left eye led to surgical treatment of vitreous and persistent subcapsular hemorrhage via pars planar vitrectomy with capsulectomy.

Association of alcohol consumption with the risk of ocular trauma.

This study was conducted to evaluate the influence of alcohol consumption on the risk of ocular trauma. We retrospectively reviewed the medical records of 1,024 patients who visited emergency department and received ophthalmologic examination from January 1 to December 31, 2009. The patients were divided into 2 groups: those with ocular trauma (n = 494) and those without (n = 530); the influence of alcohol consumption was compared between these 2 groups. In the ocular trauma group, the association of the causes and types of ocular trauma with alcohol consumption was evaluated. One of 530 patients of no trauma group and 117 (23.7%) of 494 patients of trauma group were related with alcohol intake, and the difference was statistically significant (P < 0.001). Concerning the causes, physical assault was significantly more common in alcohol-associated injury (P < 0.001). Regarding the types of injury, orbital wall fracture and hyphema showed a significant association with alcohol consumption (P < 0.001). Older age and nighttime injury were significantly related to the increased risk of alcohol-associated ocular trauma (P = 0.018 and < 0.001, respectively). In conclusion, alcohol consumption significantly increases the risk of ocular trauma.

Association of Alcohol Consumption with the Risk of Ocular Trauma

This study was conducted to evaluate the influence of alcohol consumption on the risk of ocular trauma. We retrospectively reviewed the medical records of 1,024 patients who visited emergency department and received ophthalmologic examination from January 1 to December 31, 2009. The patients were divided into 2 groups: those with ocular trauma (n = 494) and those without (n = 530); the influence of alcohol consumption was compared between these 2 groups. In the ocular trauma group, the association of the causes and types of ocular trauma with alcohol consumption was evaluated. One of 530 patients of no trauma group and 117 (23.7%) of 494 patients of trauma group were related with alcohol intake, and the difference was statistically significant (P < 0.001). Concerning the causes, physical assault was significantly more common in alcohol-associated injury (P < 0.001). Regarding the types of injury, orbital wall fracture and hyphema showed a significant association with alcohol consumption (P < 0.001). Older age and nighttime injury were significantly related to the increased risk of alcohol-associated ocular trauma (P = 0.018 and < 0.001, respectively). In conclusion, alcohol consumption significantly increases the risk of ocular trauma.

A serious drug interaction leading to spontaneous total hyphema.

A 70 year-old diabetic man receiving anti-coagulant therapy (Warfarin) for pulmonary embolism secondary to factor V Leiden deficiency, presented to the hospital for chest pain. After initial evaluation, he was started on aspirin (300 mg) and clopidogrel (300 mg). Three days after he was discharged, he presented with preseptal cellulitis complicating left upper eyelid chalazion. Initially, he was treated with several anti-microbial agents used sequentially. Although, the cellulitis resolved, he developed total hyphema of the left eye. The complication seems to have resulted from a complex interaction amongst anti-microbial agents, Warfarin and anti-platelet agents.

Neonatal hyphema in precipitous delivery with dinoprostone.

Few cases of isolated hyphema in the newborn have been reported. Spontaneous hyphema in a neonate has been associated with juvenile xanthogranuloma, leukaemia, and retinoblastoma. We report a case and review the literature of neonatal hyphema associated with precipitous vaginal delivery induced with dinoprostone.

[Spontaneous hyphema caused by Ginkgo biloba extract]. / Hyphéma spontané provoqué par l'extrait de Ginkgo biloba.

We report the first case of a patient in whom Ginkgo biloba extract proved to be the unique cause of spontaneous hyphema. Extensive ophthalmological and biological investigations were undertaken in order to assess the role of Ginkgo biloba: platelet numbering, hemostasis factors, Willebrand antigen, ristocetin cofactor, platelet glycoprotein immunophenotyping, glycoprotein expression after activation by thrombin, inflammatory markers, B-scan ultrasonography, and fluorescent iridography. No putative causes of hyphema were recorded other than Gingko biloba intake. The bleeding originated from the 12-o'clock position of the iris margin. Anamnesis identified Ginkgo biloba extract ingestion from 2 weeks before the appearance of the patient's visual trouble. Ginkgo biloba intake was stopped and the hemorrhage resolved with no recurrence during the 18 months of follow-up. Ginkgo biloba is known for platelet inhibition and is extensively used in the elderly because of its beneficial effects as a vascular protector. The clinical progression of the present case strongly suggests that Ginkgo biloba may cause hemorrhage and hyphema, even in the absence of any other predisposing factor.

Immune recovery vitritis presenting as panuveitis following therapy with protease inhibitors.

Immune reconstitution in acquired immunodeficiency syndrome (AIDS) patients on highly active anti-retroviral therapy (HAART) with cytomegalovirus (CMV) retinitis manifested as posterior segment intraocular inflammation has been reported. We report an adult HIV-positive Indian male with clinically inactive CMV retinitis who developed panuveitis with hypopyon. This was related to immune recovery mediated by combination anti-retroviral treatment, including protease inhibitors.

Hyphema after peribulbar anesthesia for cataract surgery in Fuchs' heterochromic iridocyclitis.

PURPOSE: To describe an unusual ocular sign in one patient with Fuchs' heterochromic iridocyclitis at cataract surgery. METHODS: We describe a patient with Fuchs' heterochromic iridocyclitis and cataract who developed a 1 mm hyphema observed two minutes after peribulbar anesthesia for cataract surgery. RESULTS: The patient was found to have an equivalent of the Amsler-Verrey sign. It appeared after peribulbar anesthesia and before any instrument touched the globe. It did not interfere with surgery and disappeared completely by day 2. CONCLUSION: The appearance of a hyphema after peribulbar anesthesia in Fuchs' heterochromic iridocyclitis is an unusual sign that may have the same pathophysiology as the Amsler-Verrey sign.

Antiplatelet therapy and cataract surgery.

To gain information about patients who continue antiplatelet therapy while having cataract surgery, we performed a prospective, nonrandomized study. Twenty-four of 60 phacoemulsification procedures were performed on patients who were receiving medications with antiplatelet activity prior to surgery and who continued to receive the medications for the duration of the study. The remaining 36 procedures were performed on patients who received no medications with antiplatelet activity prior to surgery. One patient in the antiplatelet therapy group had a limited peribulbar hemorrhage, and one patient not receiving antiplatelet therapy had a postoperative hyphema. Postoperative subconjunctival hemorrhages were more common in the antiplatelet therapy group (P = .001). No patient in the antiplatelet therapy group had late postoperative complications. No differences in postoperative visual acuity or intraocular pressure were observed between the groups. Our results demonstrate that phacoemulsification and posterior chamber intraocular lens implantation can be performed without serious complications in some patients who continue to use antiplatelet therapy. However, our sample sizes were too small to determine whether such therapy is associated with any increased risk of rare but serious hemorrhagic complications.

Spontaneous hyphaema as a result of systemic anticoagulation in previously abnormal eyes.

Spontaneous hyphaema in patients on systemic anticoagulants has been described in normal eyes and also in eyes with certain intraocular lenses following cataract surgery. These cases are rare and in all the reported cases the hyphaemas resolved without sequelae. Four cases are reported here of spontaneous hyphaemas in previously abnormal eyes of patients on anticoagulants. Three of these patients suffered considerable pain as a result of this. The reasons for this are discussed and early ophthalmic referral recommended if a hyphaema is suspected in these situations.