Subretinal Hemorrhages Associated with Age-Related Macular Degeneration in Patients Receiving Anticoagulation or Antiplatelet Therapy

Kuhli-Hattenbach, Claudia; Fischer, Ina; Schalnus, R.; Hattenbach, Lars‐Olof

doi:10.1016/j.ajo.2009.08.033

Cited by 52 publications

(33 citation statements)

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“…Internistische Studien belegen, dass mit zunehmender Intensität und Dauer einer gerinnungsbeeinflussenden Therapie das Blutungsrisiko für lebensbedrohliche, aber auch leichtere Blutungskomplikationen kumulativ ansteigt [25]. Einige jüngere ophthalmologische Studien konnten darüber hinaus zeigen, dass auch das submakuläre Blutungsrisiko bei exsudativer AMD durch die Einnahme gerinnungswirksamer Medikamente signifikant erhöht ist und somit der Krankheitsverlauf und die Visusprognose durch die internistische Therapie langfristig beeinflusst werden kön-nen [15,17,28].…”

Section: Massenblutung Und Gerinnungshemmer Eine Unglückliche Kombinaunclassified

“…Eine allgemeingültige Definition oder fest definierte Mindestgröße gibt es hierbei jedoch nicht. Allerdings finden sich in der Literatur im Zusammenhang mit einer subretinalen Massenblutung Flächengrößen-angaben von bis zu über 30 Papillendurchmessern (PD) [17].…”

Section: Definition Und Ursachen Subretinaler Massenblutungenunclassified

“…Blutungen bei exsudativer AMD ist durch die Einnahme gerinnungswirksamer Medikamente erhöht Erst in den letzten Jahren konnten einige wenige ophthalmologische Studien belegen, dass auch das Risiko submakulärer Blutungen bei exsudativer AMD durch die Einnahme gerinnungswirksamer Medikamente signifikant erhöht ist und somit der Krankheitsverlauf und die Visusprognose durch diese internistischen Medikamente langfristig beeinflusst werden können [15,17,28]. Unsere Arbeitsgruppe konnte an 71 AMD-Patienten mit subretinaler Blutung zeigen, dass Patienten mit gerinnungswirksamen Medikamenten statistisch signifikant größere Blutungen aufwiesen, als dies bei Patienten ohne gerinnungsbeeinflussende Medikamente der Fall war (durchschnittliche Blutungsfläche: 9,71 PD vs. 2,99 PD; p<0,0001; [17]).…”

Section: » Das Risiko Submakulärerunclassified

“…Unsere Arbeitsgruppe konnte an 71 AMD-Patienten mit subretinaler Blutung zeigen, dass Patienten mit gerinnungswirksamen Medikamenten statistisch signifikant größere Blutungen aufwiesen, als dies bei Patienten ohne gerinnungsbeeinflussende Medikamente der Fall war (durchschnittliche Blutungsfläche: 9,71 PD vs. 2,99 PD; p<0,0001; [17]). Dieser signifikante Unterschied zeigte sich sowohl bei der Einnahme von Marcumar als auch von Thrombozytenaggregationshemmern wie Acetylsalicylsäure, Clopidogrel und Ticlopidin.…”

Section: » Das Risiko Submakulärerunclassified

“…In unserer Studie zeigten alle Patienten mit Marcumar eine INR innerhalb des therapeutischen Bereichs von 2,0 bis 3,0 [17]. Diese Beobachtung deckt sich mit früheren internistischen Studien, die eindeutig auch auf ein Blutungsrisiko bei streng überwachten und engmaschig kontrollierten Patienten mit Antikoagulanzien hinweisen [20].…”

Section: Introductionunclassified

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Submakuläre Massenblutung und Gerinnungshemmer

et al. 2012

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Exudative age-related macular degeneration (ARMD) is one of the conditions which has been shown to be associated with a risk of massive subretinal hemorrhage. Patients with thick submacular hemorrhage complicating ARMD typically have a poor visual prognosis. Antiplatelet therapy with aspirin, clopidogrel or ticlopidine has significant benefits in the secondary prevention of fatal and non-fatal coronary and cerebrovascular events. Anticoagulation is frequently used in this elderly age group for a variety of other comorbidities including prosthetic heart valves, atrial fibrillation, ischemic heart disease, cerebrovascular disease and venous thromboembolism. However, it is a well established observation that the longer patients remain on anticoagulant therapy, the higher the cumulative risk of bleeding. Over the past years, there has been a rapidly growing body of literature concerning the risk of hemorrhagic ocular complications with ophthalmic surgery in patients receiving anticoagulant therapy. By contrast, there are still little data on the relationship between anticoagulation or antiplatelet therapy and spontaneous ocular hemorrhages and only few reports have focused on patients with ARMD. Just recently, several authors reported a strong association of anticoagulants and antiplatelet agents with the development of large subretinal hemorrhages in ARMD patients. Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

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Section: Massenblutung Und Gerinnungshemmer Eine Unglückliche Kombinaunclassified

Section: Definition Und Ursachen Subretinaler Massenblutungenunclassified

Section: » Das Risiko Submakulärerunclassified

Section: Introductionunclassified

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Submakuläre Massenblutung und Gerinnungshemmer

et al. 2012

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Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin

et al. 2017

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IMPORTANCE It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin.OBJECTIVE To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin.DATA SOURCES A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles.STUDY SELECTION Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis. DATA EXTRACTION AND SYNTHESISThe PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators. MAIN OUTCOMES AND MEASURESIntraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin.RESULTS Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I 2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used. CONCLUSIONS AND RELEVANCEThese results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.

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Association of Novel Oral Antithrombotics With the Risk of Intraocular Bleeding

et al. 2018

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IMPORTANCE Novel oral anticoagulation and antiplatelet therapies have become a mainstay of treatment for thromboembolic disease. However, the safety profile of these medications has not been completely characterized. OBJECTIVE To determine the risk of developing intraocular hemorrhages with novel oral antithrombotic therapy compared with that of traditional antithrombotic agents. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, a large national insurance claims database was used to generate 2 parallel analyses. All patients with incident use of dabigatran etexilate or rivaroxaban between January 1, 2010, and September 30, 2015, were compared with patients with incident use of warfarin sodium. Similarly, patients with new use of prasugrel hydrochloride were compared with those with new use of clopidogrel bisulfate. Both analyses required the patient to be in the insurance plan for at least 24 months prior to initiation of therapy and excluded patients with any previous diagnosis of intraocular hemorrhages or any prescription for the comparator medications. Furthermore, the antiplatelet analysis required a diagnosis of acute coronary syndrome or a myocardial infarction within 60 days of initiation of pharmacologic therapy. The anticoagulant analysis excluded patients with end-stage renal disease, renal transplants, and those with heart valve disease.MAIN OUTCOMES AND MEASURES Incident intraocular hemorrhages at 90 and 365 days. Multivariate Cox proportional hazards regression models were used to compare the hazard ratio (HR) of developing an intraocular hemorrhage in individuals taking novel agents compared with those taking traditional medications. RESULTS A total of 146 137 patients taking warfarin (76 714 women and 69 423 men; mean [SD] age, 69.8 [11.8] years) were compared with 64 291 patients taking dabigatran or rivaroxaban (31 576 women and 32 715 men; mean [SD] age, 67.6 [11.7] years). Cox proportional hazards regression revealed a decreased hazard for developing an intraocular hemorrhage with dabigatran or rivaroxaban at 365 days (HR, 0.75; 95% CI, 0.58-0.97; P = .03), but not at 90 days (HR, 0.73; 95% CI, 0.22-2.63; P = .13). A total of 103 796 patients taking clopidogrel (37 578 women and 66 218 men; mean [SD] age, 68.0 [11.3] years) were compared with 8386 patients taking prasugrel (1988 women and 6380 men; mean [SD] age, 61.0 [9.6] years) and no increased hazard for developing an intraocular hemorrhage with prasugrel was seen at 90 days (HR, 0.75; 95% CI, 0.29-1.92; P = .55) or 365 days (HR, 1.19; 95% CI, 0.69-2.04; P = .53). CONCLUSIONS AND RELEVANCEThese results suggest a decreased risk of intraocular hemorrhage associated with novel direct thrombin inhibitors and direct factor Xa inhibitors, but no difference for P2Y 12 inhibitors compared with traditional vitamin K anticoagulation and antiplatelet therapy, respectively.

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Subretinal Hemorrhages Associated with Age-Related Macular Degeneration in Patients Receiving Anticoagulation or Antiplatelet Therapy

Cited by 52 publications

References 29 publications

Submakuläre Massenblutung und Gerinnungshemmer

Submakuläre Massenblutung und Gerinnungshemmer

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin

Association of Novel Oral Antithrombotics With the Risk of Intraocular Bleeding

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