[Spontaneous choroidal hemorrhage associated with novel oral anticoagulants: A report of two cases and literature review]

Abstract

New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto^®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa^®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.

Keywords: Anticoagulants oraux directs; Choroidal hemorrhage; Dabigatran; Direct oral anticoagulants; Expulsive hemorrhage; Hémorragie choroïdienne; Hémorragie expulsive; Retina; Rivaroxaban; Rétine.