How to manage a conjunctival hemorrhage in a patient on anticoagulation (anticoagulant) therapy, such as warfarin or Direct Oral Anticoagulants (DOACs) like apixaban (apixaban) or rivaroxaban (rivaroxaban)?

From the Guidelines

Managing a conjunctival hemorrhage in a patient on anticoagulation therapy generally requires conservative treatment and monitoring rather than medication changes. For most patients, reassurance that the condition is benign and self-limiting is the primary intervention, with resolution typically occurring within 1-2 weeks without specific treatment 1. Artificial tears such as preservative-free carboxymethylcellulose drops can be used 4-6 times daily to reduce irritation and dryness. Cold compresses applied for 10 minutes several times daily during the first 24-48 hours may help reduce discomfort and limit bleeding. Patients should avoid rubbing the eye and consider temporarily discontinuing aspirin if it's being taken for primary prevention (only after consulting their physician).

Importantly, anticoagulation therapy (warfarin, apixaban, rivaroxaban, etc.) should not be discontinued solely for a conjunctival hemorrhage, as the risk of thrombotic events outweighs the benefits of faster resolution 1. Medical attention should be sought if the hemorrhage is extensive, recurrent, associated with trauma, accompanied by vision changes, or if the patient experiences significant pain. This conservative approach is appropriate because conjunctival hemorrhages result from rupture of small blood vessels on the eye surface, and while anticoagulants may increase bleeding duration, the condition remains self-limiting and does not threaten vision.

In cases where bleeding is more severe, specific reversal agents like andexanet alfa for apixaban or rivaroxaban may be considered, but this is typically not necessary for conjunctival hemorrhages unless they are part of a more severe bleeding event 1. The decision to use reversal agents should be made on a case-by-case basis, considering the severity of the bleeding and the patient's risk of thrombotic events.

Key considerations for managing conjunctival hemorrhage in patients on anticoagulation include:

• Conservative management with artificial tears and cold compresses
• Avoidance of rubbing the eye
• Potential temporary discontinuation of aspirin for primary prevention under physician guidance
• Monitoring for signs of more severe bleeding or complications
• Rare consideration of reversal agents for severe bleeding events, guided by the latest clinical guidelines and patient-specific factors 1.

From the FDA Drug Label

Ocular hemorrhage (including conjunctival hemorrhage) The FDA drug label mentions conjunctival hemorrhage as a possible adverse reaction, but it does not provide specific guidance on managing conjunctival hemorrhage in patients on anticoagulation therapy, such as apixaban or rivaroxaban.

• Key points:
  • Conjunctival hemorrhage is listed as a less common adverse reaction in apixaban-treated patients undergoing hip or knee replacement surgery.
  • The label does not provide specific recommendations for managing conjunctival hemorrhage in patients on anticoagulation therapy.
  • In general, management of bleeding complications in patients on anticoagulants may involve discontinuing the anticoagulant and initiating appropriate therapy, but this is not explicitly stated for conjunctival hemorrhage 2.
  • For rivaroxaban, the label mentions that overdose may lead to hemorrhage, and discontinue rivaroxaban and initiate appropriate therapy if bleeding complications associated with overdosage occur 3.

From the Research

Management of Conjunctival Hemorrhage on Anticoagulation

• The management of conjunctival hemorrhage in patients on anticoagulation therapy, such as warfarin or Direct Oral Anticoagulants (DOACs) like apixaban or rivaroxaban, requires careful consideration of the patient's overall health and the risk of bleeding complications 4, 5, 6, 7.
• In cases of massive spontaneous subconjunctival hemorrhage, cessation and reversal of anticoagulation may be necessary, as seen in a case report of a patient on therapeutic warfarin 4.
• The risk of intraocular hemorrhage with anticoagulants has been assessed in several studies, with warfarin having the highest signal of association with choroidal hemorrhage, and rivaroxaban having the highest signal of association with both retinal and vitreous hemorrhage 5.
• DOACs, including apixaban, dabigatran, and rivaroxaban, have been associated with ocular bleeding complications, including submacular hemorrhage, vitreous hemorrhage, and hyphema 6.
• Rivaroxaban anticoagulation has been correlated with spontaneous vitreous hemorrhage, particularly during the transition period when patients are switched from baseline anticoagulant to rivaroxaban therapy and are taking both anticoagulants simultaneously 7.

Considerations for Patient Care

• Ophthalmologists should be aware of the potential hemorrhagic complications associated with anticoagulant therapy and obtain consultation with primary providers regarding cessation guidelines 6.
• A thorough ocular examination is paramount for patients on anticoagulation therapy, as recurrent subconjunctival hemorrhages can be a sign of underlying conditions, such as ocular adnexal lymphoma 8.
• The management of conjunctival hemorrhage in patients on anticoagulation therapy should take into account the patient's individual risk factors and the potential benefits and risks of anticoagulant therapy 4, 5, 6, 7.