How to manage conjunctival injections in patients on apixaban (eliquis)?

Management of Conjunctival Injections in Patients on Apixaban

For patients with non-severe conjunctival injections while on apixaban, continue the anticoagulant medication and implement local bleeding control measures rather than suspending anticoagulation therapy. 1

Classification of Severity

• Non-severe conjunctival injections: Characterized by localized redness without significant vision impairment or intraocular pressure elevation 1
• Severe conjunctival injections: Associated with vision loss, pain, intraocular hemorrhage (vitreous, choroidal, or retinal), or elevated intraocular pressure 2, 3

Management Algorithm

For Non-Severe Conjunctival Injections:

• Continue apixaban therapy to avoid increasing thrombotic risk 1
• Implement first-line local treatments:
  • Lubricating eye drops or artificial tears 1
  • Topical vasoconstrictors to reduce redness 1
  • Cold compresses to reduce inflammation 1
  • Avoid eye rubbing to prevent exacerbation 1

For Severe Conjunctival Injections with Intraocular Hemorrhage:

• Assess the severity of bleeding and impact on vision or intraocular pressure 2
• If life-threatening or occurring at a critical site (such as intraocular):
  • Consider temporary discontinuation of apixaban 4
  • For severe bleeding with significant vision threat, consider administering andexanet alfa (specific reversal agent for apixaban) 4
  • If andexanet alfa is unavailable, consider prothrombin complex concentrate (PCC) or activated PCC 4
• Consult ophthalmology immediately for specialized evaluation and management 2

Important Considerations

• Point-of-care ultrasound may be valuable to identify associated vitreous hemorrhage in cases of severe eye bleeding 2
• The risk of intraocular hemorrhage has been reported with apixaban use, though less frequently than with other anticoagulants 3, 5
• Shared decision-making between the emergency physician, ophthalmologist, and patient regarding anticoagulation reversal is essential when severe eye bleeding occurs 2
• The half-life of apixaban is 6-15 hours in patients with normal renal function, which should be considered if temporary suspension is decided 1

Resumption of Apixaban After Suspension

• For low-risk procedures or after non-severe bleeding control, resume apixaban approximately 24 hours after bleeding is controlled 1
• For high-risk procedures or severe intraocular hemorrhage, consider resuming apixaban 48-72 hours after bleeding is controlled 1
• Evaluate the balance between thrombotic risk and re-bleeding risk before resuming anticoagulant therapy 1

Pitfalls and Caveats

• Avoid unnecessary discontinuation of apixaban for minor conjunctival injections as this increases thrombotic risk 4, 1
• Be aware that apixaban-associated ocular bleeding may be more difficult to control than spontaneous bleeding 5
• Consider that some topical ophthalmic anti-VEGF agents (bevacizumab, ranibizumab) used for corneal neovascularization may interact with systemic anticoagulation effects 6, 7
• Monitor for signs of increased intraocular pressure or vision changes that may indicate progression to more severe bleeding 2