What is the management approach for a patient with a ruptured blood vessel in the eye, change in vision, and on warfarin (anticoagulation therapy)?

Management of Ruptured Blood Vessel in the Eye with Vision Change in a Warfarin Patient

This patient requires immediate ophthalmologic evaluation to determine the location and severity of intraocular bleeding, as vision change suggests potentially sight-threatening hemorrhage (vitreous or retinal) rather than benign subconjunctival hemorrhage—warfarin should NOT be routinely discontinued for eye bleeding, but management depends critically on bleeding location and INR level. 1

Immediate Assessment Required

Determine the exact location of bleeding through urgent ophthalmologic examination:

• Subconjunctival hemorrhage (superficial, red patch on white of eye, no vision change): This is benign and requires no warfarin adjustment 2, 3
• Intraocular hemorrhage (vitreous or retinal bleeding with vision change): This is potentially serious and requires specific management based on severity 1

Check INR immediately to determine if bleeding is occurring at therapeutic or supratherapeutic levels 1

Management Algorithm Based on Bleeding Location

If Subconjunctival Hemorrhage (No Vision Change)

Continue warfarin without interruption 1

• Subconjunctival hemorrhage in warfarin patients occurs at a rate of only 0.35% and causes no ophthalmic complications 3
• Vision change would NOT occur with simple subconjunctival hemorrhage—if vision is truly affected, this is NOT the diagnosis 2, 3
• No warfarin dose adjustment needed if INR is therapeutic 3

If Intraocular Hemorrhage (Vitreous or Retinal) WITH Vision Change

This represents bleeding in a critical anatomic site (intraocular) and requires reversal if INR is elevated or bleeding is severe 1

For INR in Therapeutic Range (2.0-3.0) with Mild-Moderate Bleeding:

• Withhold warfarin temporarily and monitor closely 4, 5
• Coordinate with ophthalmology regarding need for urgent vitreoretinal surgery 6, 7
• Do NOT give vitamin K if surgery is not planned, as this creates warfarin resistance 1
• Resume warfarin once bleeding stabilizes, typically at 80% of previous dose 4, 5

For INR >3.0 or Life-Threatening Intraocular Bleeding:

Administer reversal agents immediately 1:

• 4-factor prothrombin complex concentrate (4F-PCC) 25-50 U/kg IV PLUS vitamin K 5-10 mg by slow IV infusion over 30 minutes 1
• Target INR <1.5 for life-threatening bleeding in critical anatomic sites 1
• Fresh frozen plasma (FFP) only if PCC unavailable, but PCC is strongly preferred due to faster action and lower volume 1
• Never use recombinant Factor VIIa (rFVIIa) as first-line reversal agent 1

Critical Distinction: Minor vs. Major Eye Procedures

For cataract surgery or minor eye procedures, warfarin can be safely continued 1:

• The American College of Chest Physicians found that continuing warfarin during cataract procedures does not increase bleeding risk compared to stopping it 1
• Eye surgery for cataracts or glaucoma is "usually associated with very little bleeding" and frequently performed without warfarin alterations 1

However, for vitreoretinal surgery or procedures on bleeding eyes, warfarin management must be individualized 1:

• If INR is therapeutic (2.0-3.0), vitreoretinal surgery can proceed safely without stopping warfarin in most cases 6, 7
• One study of 25 patients undergoing vitreoretinal surgery on warfarin (median INR 2.0) showed successful outcomes with only one drainage-related hemorrhage 7
• Another study of 60 warfarin patients (median INR 2.3) undergoing vitrectomy showed no increase in suprachoroidal hemorrhages compared to controls 6

Warfarin and Retinal Vein Occlusion Risk

Patients on warfarin with retinal detachment are significantly more likely to present with vitreous hemorrhage 6:

• 12 of 60 warfarin patients (20%) with rhegmatogenous retinal detachment had vitreous hemorrhage at presentation versus only 4 of 60 controls (6.7%), p=0.04 6
• This suggests warfarin may worsen bleeding from underlying retinal pathology 6

Common Pitfalls to Avoid

Never stop warfarin reflexively for eye bleeding without determining the location and severity 1:

• The risk of stopping warfarin in high-risk patients (mechanical valves, recent thromboembolism) is 10-20% per year for thromboembolism 1
• Even 3 days off warfarin carries 0.08-0.16% thromboembolism risk in worst-case scenarios 1

Never use high-dose vitamin K (≥10 mg) for non-life-threatening situations 1, 4:

• High-dose vitamin K causes warfarin resistance for up to one week 1
• For INR 5-9 without major bleeding, use only 1-2.5 mg oral vitamin K 1, 4

Never assume all "ruptured blood vessels" in the eye are the same 2, 3:

• Subconjunctival hemorrhage is cosmetically alarming but medically insignificant 2, 3
• Intraocular hemorrhage with vision change is potentially sight-threatening and requires urgent intervention 1

Coordinate closely with the patient's cardiologist or anticoagulation clinic before making warfarin changes 1, 7:

• The decision to stop warfarin must balance thrombotic risk (mechanical valves, atrial fibrillation with prior stroke) against bleeding severity 1
• High-risk patients may require bridging with heparin if warfarin must be stopped 1

Monitoring After Intervention

If warfarin was withheld or reversed, recheck INR within 24-48 hours 4, 5:

• Continue monitoring every 24-48 hours until INR stabilizes in therapeutic range 4, 5
• Resume warfarin at reduced dose (typically 80% of previous) once hemostasis achieved 4, 5
• Investigate cause of elevated INR if present: new medications, dietary changes, acute illness, liver/renal dysfunction 1, 4