Treatment of Nosebleed in an Elderly Patient with Glaucoma
In elderly patients with glaucoma experiencing epistaxis, use nasal saline moisturization and firm nasal compression as first-line treatment, avoiding topical vasoconstrictors like oxymetazoline due to the risk of worsening glaucoma. 1, 2
Immediate Management Algorithm
Step 1: Initial Compression (First-Line Treatment)
- Apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without interruption 1
- Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway 3
- Do not check if bleeding has stopped before the full compression time, as premature release is the most common cause of treatment failure 3
Step 2: Critical Safety Consideration for Glaucoma Patients
- Avoid oxymetazoline (Afrin) and phenylephrine nasal sprays in patients with glaucoma, as vasoconstrictors can cause systemic complications and worsen glaucoma 1, 2
- This is particularly important in elderly patients, as ipratropium bromide (an anticholinergic) can also worsen glaucoma and requires use of a mouthpiece if administered 4
Step 3: If Bleeding Persists After Compression
- Continue compression for an additional 5-10 minutes 1
- Consider nasal packing with resorbable materials if bleeding continues despite 15-30 minutes of proper compression 3
- Refer to otolaryngology if bleeding remains uncontrolled, as elderly patients with posterior epistaxis have a 3.4% 30-day all-cause mortality rate 1
Prevention Strategy (Essential for Long-Term Management)
Daily Nasal Moisturization
- Apply nasal saline spray or gel 2-4 times daily to maintain nasal moisture, which resolves up to 65% of recurrent epistaxis cases 1, 2
- Continue moisturization even after bleeding resolves to prevent recurrence 1, 2
- This is the safest and most effective preventive strategy for glaucoma patients who cannot use vasoconstrictors 1, 2
Special Considerations in Elderly Glaucoma Patients
High-Risk Population
- Elderly patients aged 85+ are 3.24 times more likely to present with epistaxis compared to those under 65 1
- 33% of elderly epistaxis patients have hypertension, and 15% are on long-term anticoagulation 1
Blood Pressure Management
- Do not aggressively lower blood pressure during active epistaxis, as this can cause end-organ ischemia 1
- This is particularly relevant given the cardiovascular comorbidities common in elderly glaucoma patients 5, 6
Medication Review
- Review the patient's glaucoma medications, as systemic absorption of topical beta-blockers used for glaucoma can affect cardiovascular status 7, 8
- Anticholinergic medications and certain antidepressants can predispose to glaucoma and should be documented 5
Common Pitfalls to Avoid
- Never use oxymetazoline or phenylephrine continuously for more than 3-5 days even if glaucoma were not a concern, due to risk of rhinitis medicamentosa 1, 2
- Do not release nasal compression prematurely to check if bleeding has stopped 3
- Do not use ipratropium bromide without a mouthpiece in glaucoma patients, as it can worsen the condition 4