warfarin and Retinal-Vein-Occlusion

Retinal vein occlusion is a common and important cause of vision loss. In general, knowledge about this condition is scant within an internist's practice but the condition is relevant because of its association with other chronic ailments. A diagnosis of RVO should prompt the investigation of conditions needing chronic management in these patients. In this review we summarize the clinical presentation of RVO, its classification, associated risk factors, and treatment focused in the internist's scope of practice.

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Platelet Aggregation Inhibitors; Prognosis; Retinal Vein; Retinal Vein Occlusion; Warfarin

Venous thrombosis typically involves the lower extremities. Rarely, it can occur in cerebral, splanchnic, or renal veins, with a frightening clinical impact. Other rare manifestations are upper-extremity deep vein thrombosis, that can complicate with pulmonary embolism and post-thrombotic syndrome, and retinal vein occlusion, significantly affecting the quality of life. This review is focused on venous thromboses at unusual extra-abdominal sites. Local infections or cancer are frequent in cerebral sinus-venous thrombosis. Upper-extremity deep vein thrombosis is mostly due to catheters or effort-related factors. Common risk factors are inherited thrombophilia and oral contraceptive use. Acute treatment is based on heparin; in cerebral sinus-venous thrombosis, local or systemic fibrinolysis should be considered in case of clinical deterioration. Vitamin-K antagonists are recommended for 3-6 months; indefinite anticoagulation is suggested for recurrent thrombosis or unprovoked thrombosis and permanent risk factors. However, such recommendations mainly derive from observational studies; there are no data about long-term treatment of retinal vein occlusion.

Topics: Anticoagulants; Catheters; Contraceptives, Oral; Heparin; Humans; Postthrombotic Syndrome; Pulmonary Embolism; Retinal Vein Occlusion; Risk Factors; Thrombophilia; Upper Extremity Deep Vein Thrombosis; Vitamin K; Warfarin

Antiphospholipid syndrome is a rare cause of ocular vaso-occlusive disease, but is associated with significant systemic morbidity and mortality. Thus, early diagnosis and treatment is essential.. Although the pathophysiology of antiphospholipid syndrome continues to be poorly understood, there has been continued progress with regard to the relationship between antiphospholipid antibody and its target, β-2-glycoprotein I. Due to numerous limitations with standard serologic evaluation, new approaches to the evaluation of patient serum are being considered. New guidelines for the treatment and management of antiphospholipid antibody syndrome have been established by the 13th International Committee on Antiphospholipid Antibodies.. A better understanding of the pathophysiology behind antiphospholipid antibody syndrome has led to novel approaches in the diagnosis and treatment of this disease.

Topics: Antibodies, Antiphospholipid; Antiphospholipid Syndrome; Aspirin; beta 2-Glycoprotein I; Humans; Hydroxychloroquine; Retinal Artery Occlusion; Retinal Vein Occlusion; Warfarin

Optimal management of retinal vein occlusion (RVO) is still a matter of debate. Antithrombotic and fibrinolytic drugs have been investigated after demonstration of a role of thrombosis in the complex pathogenesis of the disease. Aim of our study was to systematically summarise best available evidence on the acute treatment and on the secondary prevention of RVO with antithrombotic and fibrinolytic drugs. A computer-assisted search of the MEDLINE and EMBASE electronic databases up to January 2009 was performed. Two review authors selected all published randomised controlled trials (RCTs) from the search, assessed study quality and extracted data. Based on Jadad's score, RCTs were stratified into three quality categories. A total of six RCTs were included. Only one RCT of high quality was identified. A total of 384 patients were investigated, 234 with central retinal vein occlusion and 150 with branch retinal vein occlusion. No study enrolled more than 100 patients. Three studies compared therapeutic doses of low-molecular-weight heparin (LMWH) with low-dose aspirin, one study compared ticlopidine with placebo and two studies compared intravenous fibrinolytic therapy followed by warfarin or aspirin with either haemodilution or no treatment. A partial improvement of visual acuity was reported in every study, independently of the study drug. No long-term secondary prevention study was published. The present systematic review suggests that antithrombotic therapy, in particular LMWH, may be part of the therapeutic armamentarium for patients with recent onset RVO. No firm recommendation can be provided given the limited available evidence.

Topics: Aspirin; Drug Evaluation; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Randomized Controlled Trials as Topic; Retinal Vein Occlusion; Ticlopidine; Treatment Outcome; Visual Acuity; Warfarin

Recurrent thromboembolic events may occur after termination of anticoagulant therapy for acute venous thromboembolism (VTE) using oral direct thrombin inhibitor ximelagatran.. Patients with VTE recruited at the German study centres were followed-up for an additional 18 months, treated initially with 2x36 mg ximelagatran daily or with enoxaparin/warfarin over 6 months (THRIVE Treatment study) and 2x24 mg ximelagatran daily or placebo over 18 months (THRIVE III study). Recurrent VTE and the combined outcome events consisting of recurrent VTE, other thrombotic complication, major bleeding and mortality were analysed.. In the THRIVE Treatment study, no patient suffered from a recurrent VTE, but 1 patient randomised to enoxaparin/warfarin experienced major bleeding. During follow-up, 4/32 and 3/32 patients initially randomised to ximelagatran and enoxaparin/warfarin developed recurrent VTE (p=0.7024). No major bleed occurred. One patient in each group died. The incidences of the combined outcome events were not different (p=0.9326). In the THRIVE III study, 0/9 versus 5/14 patients randomised to ximelagatran and placebo developed recurrent VTE including 1 fatal pulmonary embolism (p=0.0501). During follow-up, 3/9 and no patients initially randomised to ximelagatran and placebo developed recurrent VTE. One and 3 other outcome events occurred in patients initially randomised to ximelagatran or placebo. During follow-up, recurrent VTE (p=0.6893) and combined outcome events (p=0.3642) were not different between the groups.. The results of the follow-up studies suggest that thromboembolic events may re-occur in patients with acute VTE after termination of treatment with both vitamin K-antagonists and ximelagatran.

Topics: Administration, Oral; Anticoagulants; Arteries; Azetidines; Benzylamines; Drug Therapy, Combination; Enoxaparin; Follow-Up Studies; Germany; Hemorrhage; Humans; Incidence; International Normalized Ratio; Muscle, Skeletal; Prospective Studies; Recurrence; Retinal Vein Occlusion; Time Factors; Venous Thrombosis; Warfarin

We reviewed the records of 10 patients who had impending central retinal vein occlusion in order judge whether anticoagulant treatment with warfarin potassium (Warfarin) was indicated.. 6 men and 4 women, ranging in age from 25 to 83 (average 55) years were studied.. Of 6 eyes, retinal hemorrhage disappeared completely within 6 months. Four patients whose visual acuity was 0.1 or less at one month needed photocoagulation. Four other patients whose late venous circulation time at fluorescein angiography improved within 30 seconds had good visual prognosis, 3 eyes of 4 patients aged 65 or older were not successful in regaining their visual acuity.. Warfarin was not effective for patients who had clearly lost their visual acuity and the elderly in this series. Late venous circulation time at fluorescein angiography was a useful index for this treatment.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Female; Fluorescein Angiography; Humans; Male; Middle Aged; Retinal Vein Occlusion; Treatment Outcome; Visual Acuity; Warfarin

The combined effect of prostaglandin E1, stellate ganglion block, warfarin potassium and photocoagulation on 66 cases (eyes) of retinal vein occlusion was investigated immediately after, and 3 months and 6 months after final treatment. The time between onset and treatment was 2 months or less. Macular hemorrhage and edema were observed in all cases. The effectiveness rate 6 months after treatment was 35% in hemorrhagic central retinal vein occlusion and 63% in branch retinal vein occlusion. Visual acuity increased gradually with time from immediately after to 6 months after treatment. The effectiveness of treatment including warfarin potassium was lower than that of treatment without warfarin potassium in branch retinal vein occlusion, and many cases showed a marked decrease of visual acuity which might be related to the prolonged hemorrhage. These results suggest that combining prostaglandin E1, stellate ganglion block and photocoagulation in retinal vein occlusion produces better effects on visual acuity than ordinary treatment or spontaneous regression.

Topics: Aged; Alprostadil; Anticoagulants; Autonomic Nerve Block; Combined Modality Therapy; Female; Humans; Laser Coagulation; Male; Middle Aged; Retinal Vein Occlusion; Stellate Ganglion; Visual Acuity; Warfarin

We investigated the prevalence of retinal vascular occlusion and intraocular bleeding and compare their risks in patients undergoing anticoagulant therapy, either with non-vitamin K-antagonist oral anticoagulants (NOAC) or warfarin. We performed a cohort study (January 2015 to April 2018) in 281,970 patients with nonvalvular atrial fibrillation (AF) using health claims in the nationwide database of the Health Insurance Review and Assessment service of Korea. A Cox-proportional hazard regression was used to calculate the hazard ratio (HR) for retinal vascular occlusion or intraocular bleeding. The HR of retinal vascular occlusion was estimated to 1.59 (95% confidence interval [CI], 1.35-1.86) for NOAC users compared to that with warfarin users. Among the various types of NOACs, all NOACs showed higher risk of retinal vascular occlusion than did warfarin. For intraocular bleeding, the HR was estimated to be 0.86 (95% CI, 0.75-0.98) for NOAC users compared with that with warfarin users. The risk of retinal vascular occlusion was higher in NOAC users than in warfarin users, while the risk of intraocular bleeding was lower with NOAC therapy. NOACs were not found to be as effective as warfarin for retinal vascular occlusion, but safe in terms of intraocular bleeding.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Cohort Studies; Eye Hemorrhage; Female; Humans; Insurance Claim Review; Male; Prevalence; Republic of Korea; Retinal Vein Occlusion; Warfarin

Retinal vein occlusion (RVO) and retinal artery occlusion (RAO) cause significant visual impairment. The role of thrombophilia and cardiovascular testing is uncertain, and optimal treatment strategies have not been determined. We reviewed medical records of 39 patients with RVO and RAO (23 women and 16 men). Thrombophilia and cardiovascular evaluations were performed and outcomes were reviewed. In all, 24 (61.5%) patients had at least 1 thrombophilia. Elevated factor VIII levels were found in RVO (n = 5) but not in RAO. There are no other significant differences in thrombophilias in RVO compared to those in RAO. Most patients had hypertension(41.2% RAO and 55% RVO) and hyperlipidemia (35.5% RAO and 81.8% RVO). In all, 4 women were using oral contraceptives, 2 were pregnant or postpartum. Follow-up data was available for 28 patients (13 RAO, 15 RVO). Nineteen were treated with aspirin, four with warfarin, and one with low molecular weight heparin. Eight patients reported improvement in vision at time of follow-up (5 RAO, 3 RVO). Multiple risk factors are associated with RVO and RAO, and a complete assessment should include thrombophilia and cardiovascular studies.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Female; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Postpartum Period; Pregnancy; Pregnancy Complications; Retinal Vein Occlusion; Retrospective Studies; Risk Factors; Thrombophilia; Warfarin

To investigate systematically the role of anti-platelet-aggregating drugs or anticoagulants in central retinal vein occlusion (CRVO) and hemi-CRVO.. Cohort study.. Six hundred eighty-six consecutive patients with CRVO (567 patients, 585 eyes) and nonischemic hemi-CRVO (119 patients, 122 eyes).. At first visit, all patients had a detailed ophthalmic and medical history (including the use of anti-platelet aggregating drugs or anticoagulants), and comprehensive ophthalmic and retinal evaluation. Visual evaluation was carried out by recording visual acuity, using the Snellen visual acuity chart, and visual fields with a Goldmann perimeter. The same ophthalmic evaluation was performed at each follow-up visit. At the initial visit, CRVO and hemi-CRVO were classified as nonischemic and ischemic.. Visual acuity, visual fields, and severity of retinal hemorrhages.. All 3 types of CRVO, showed a significantly greater severity of retinal hemorrhages among aspirin users than nonusers (P<0.001). Initial visual acuity and visual fields were significantly worse in aspirin users than nonusers in nonischemic CRVO and hemi-CRVO, but did not differ for ischemic CRVO. Among patients with nonischemic CRVO who initially had 20/60 or better visual acuity, there was a significant association of aspirin use with visual acuity deterioration. The odds ratio of visual acuity deterioration, adjusting for age, diabetes, ischemic heart disease, and hypertension, for aspirin users relative to nonusers was 2.24 (95% confidence interval [CI], 1.14-4.41; P = 0.020). Of those whose macular edema resolved, overall cumulative visual acuity outcome also suggested a higher percentage with deterioration among aspirin users, odds ratio for deterioration of 3.62 (95% CI, 0.97-13.54; P = 0.05) for aspirin users relative to nonusers. For the nonischemic CRVO patients with 20/70 or worse visual acuity at the initial visit, after resolution of macular edema, improvement in visual acuity was less likely in the aspirin users than in nonusers (odds ratio, 0.18; 95% CI, 0.04-0.72; P = 0.016).. Findings of this study indicate that, for patients with CRVO and hemi-CRVO, the use of aspirin, other anti-platelet aggregating agents, or anticoagulants was associated with a worse visual outcome and no apparent benefit.. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Cohort Studies; Dipyridamole; Female; Humans; Macular Edema; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Retinal Hemorrhage; Retinal Vein Occlusion; Treatment Outcome; Visual Acuity; Visual Field Tests; Visual Fields; Warfarin; Young Adult

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Retinal Vein Occlusion; Treatment Outcome; Venous Thrombosis; Warfarin

To investigate risk factors for central retinal vein occlusion (CRVO).. Retrospective case-control study.. Consecutive patients with CRVO examined from July 1, 2005 through July 31, 2006 were compared with an historical gender- and age-matched control group of patients with ocular problems other than vascular occlusive disease from the same referral practice. Risk factors for CRVO were evaluated.. The 144 patients in the CRVO group, 87 males and 57 females, had a mean age of 69.6 years (+/-13.6 years). CRVO was associated with hypertension (P < .001), diabetes mellitus (P = .047), glaucoma (P < .001), atrial fibrillation (P = .036), angiotensin-converting enzyme inhibitor use (P = .022), aspirin use (P < .001), and warfarin use (P = .011) by univariate analyses. Postmenopausal estrogen use was more common among women in the control group (P = .029). Multivariate logistic regression found the independent predictors for CRVO to be: glaucoma (adjusted odds ratio [OR], 4.75; P < .001), aspirin use (adjusted OR, 2.66; P = .001), and warfarin use (adjusted OR, 3.34; P = .005).. We found many of the same risk factors previously identified for CRVO by other studies, but we identified both aspirin and warfarin use to be independent risk factors for CRVO. Although these findings suggest the vasculopathic and prothrombotic risks in some patients may not be addressed adequately by antithrombotic therapy, they also suggest that the pathogenesis of CRVO may be more complicated than just the development of a primary thrombus within the vein.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aspirin; Case-Control Studies; Female; Glaucoma; Humans; Male; Middle Aged; Retinal Vein Occlusion; Retrospective Studies; Risk Factors; Warfarin

We present a case of protein S deficiency causing central retinal vein occlusion treated with anticoagulation, which includes heparin followed by oral warfarin therapy. This article highlights the importance of looking for other possible causes of central retinal vein occlusion, especially in younger patients with negative initial investigations.

Topics: Adult; Anticoagulants; Enoxaparin; Follow-Up Studies; Humans; Male; Protein S Deficiency; Retinal Hemorrhage; Retinal Vein Occlusion; Vision Disorders; Visual Acuity; Warfarin

Topics: Activated Protein C Resistance; Anticoagulants; Factor V; Fluorescein Angiography; Heparin; Humans; Point Mutation; Protein S Deficiency; Retinal Vein Occlusion; Warfarin

To describe the clinical features of persons who developed central retinal vein occlusion (CVO) while being treated with Coumadin for chronic anticoagulation.. In a retrospective, comparative, noninterventional case series of patients diagnosed with CVO while being treated with Coumadin as a systemic anticoagulant, visual and anatomical outcomes were compared with those for a cohort of patients diagnosed with CVO who were not treated with any systemic anticoagulation.. Fourteen eyes of 14 patients treated with Coumadin were identified. At presentation, the median international normalization ratio (INR) was 2.20 (range, 1.3-5.0). Eight patients (57%) had a therapeutic INR at the time of CVO. Their visual acuity and perfusion status were similar to those of patients with subtherapeutic INR. At the last follow-up (median, 16 months), visual acuity and perfusion status of the group of 14 eyes were similar to baseline findings (P = 0.62). Clinical features and outcomes were similar to those for a cohort of patients with CVO who were not being treated with systemic anticoagulation.. CVO can occur in patients being treated with Coumadin for systemic anticoagulation. Final visual acuity and perfusion status were similar to those in a cohort of patients with CVO who were not treated with Coumadin. Although visual acuity is unaffected, ensuring that the INR for these patients remains in the therapeutic range may be important to help prevent secondary systemic thrombotic and embolic disease.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation; Eye; Female; Humans; International Normalized Ratio; Male; Middle Aged; Retinal Vein Occlusion; Retinal Vessels; Retrospective Studies; Thrombosis; Visual Acuity; Warfarin

Concurrent development of retinal venous drainage and cerebral venous thrombosis has not been reported. Case Description We describe a 23-year-old man with bilateral central retinal vein occlusions and cerebral venous thrombosis. Initially observed bilateral hemorrhagic retinopathy and thrombus in the right transverse sinus of the patient began to resolve after 2 weeks of low-molecular-weight heparin. Hemorrhagic retinopathy progressively improved to previous visual acuity and the right lateral sinus remained patent by maintenance of anticoagulation with warfarin.. The present case shows effectiveness of low-molecular-weight heparin for the initial management of hemorrhagic retinopathy of central retinal vein occlusion combined with cerebral venous thrombosis.

Topics: Adult; Anticoagulants; Cerebral Veins; Heparin; Humans; Male; Retinal Vein Occlusion; Time Factors; Venous Thrombosis; Warfarin

To describe development of retinal vein occlusion (RVO) in patients anticoagulated with warfarin.. Retrospective, observational case series.. Thirteen patients drawn from a private retina practice.. Review of clinical records, laboratory results, color fundus photographs, and fluorescein angiograms.. Primary measures were international normalized ratio (INR), visual acuity, and concurrent systemic disease.. The female-to-male ratio was 7 to 6. Age range was 44 to 86 years, with a median age of 73 years. Two patients had systemic lupus erythematosus, 7 had hypertension, and 2 had primary open-angle glaucoma. Two had laboratory abnormalities: 1 with a combination of lupus anticoagulant and anticardiolipin antibodies and 1 with a combination of hyperhomocystinemia and low antithrombin III. Three patients were taking acetylsalicylic acid in addition to warfarin at the time of the RVO. The INRs at the time of RVO were 0.9 to 3.8, with 9 of 13 <==2.0.. Anticoagulation with warfarin does not preclude RVO in predisposed patients, nor does combination therapy with warfarin and acetylsalicylic acid. Attention to keeping the INR >2.0 may be helpful.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Female; Humans; Male; Middle Aged; Retinal Vein; Retinal Vein Occlusion; Retrospective Studies; Warfarin

To report a case of a 33-year-old white woman in whom retinal venous thromboses developed secondary to heparin-induced antiheparin-platelet antibodies.. Interventional case report.. The patient underwent complete ophthalmic and medical examinations. Laser Doppler measurement of retinal blood circulation also was performed.. Prolonged anticoagulation with thrombin inhibitors and warfarin.. Visual symptoms, retinal appearance on clinical examination, and measurement of retinal blood flow by laser Doppler technique.. The patient experienced a scotoma in the visual field of the left eye, left retinal venous thrombosis, decreased venous blood flow in the left eye, and heparin-induced antiheparin-platelet antibodies in serum. After intervention, the visual symptoms and retinal appearance improved, and retinal blood flow normalized.. Heparin-induced antiheparin-platelet antibody can lead to thrombosis of the ocular circulation. This index case, which is the first one ever reported in association with antiheparin-platelet antibodies, further illustrates the potential side effects of heparin and widens the spectrum of complications of heparin-induced thrombocytopenia (HIT) and HIT thrombosis syndrome (HITTS).

Topics: Adult; Anticoagulants; Autoantibodies; Female; Fluorescein Angiography; Heparin, Low-Molecular-Weight; Humans; Laser-Doppler Flowmetry; Platelet Factor 4; Regional Blood Flow; Retinal Vein Occlusion; Retinal Vessels; Scotoma; Thrombocytopenia; Warfarin

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Aspirin; Drug Therapy, Combination; Female; Fluorescein Angiography; Humans; Platelet Aggregation Inhibitors; Retinal Artery Occlusion; Retinal Vein Occlusion; Visual Acuity; Warfarin

Topics: Adult; Anticoagulants; Female; Fluorescein Angiography; Humans; Hypertension, Pulmonary; Isosorbide Dinitrate; Retinal Vein Occlusion; Vasodilator Agents; Visual Acuity; Warfarin

Topics: Adult; Aged; Anti-Inflammatory Agents; Cyclophosphamide; Female; Fluorescein Angiography; Fundus Oculi; Glucocorticoids; Humans; Infusions, Intravenous; Macular Edema; Male; Methylprednisolone; Papilledema; Retinal Vein Occlusion; Visual Acuity; Warfarin

To report a 31-year-old healthy patient with retinal venous occlusion in his left eye attributable to primary antiphospholipid antibody syndrome.. The patient was examined clinically. Multiple serologic and clinical investigations were performed to determine the causative disease. He was closely followed up for more than 3 years.. The presence of lupus anticoagulant in our patient was indicated by a kaolin clotting time index of 27 (normal, <17) and confirmed by the demonstration of IgG antibodies against phospholipids. After long-term oral anticoagulant treatment for 2 years, lupus anticoagulant levels returned to normal, and therapy was stopped. No further thrombotic event occurred during follow-up.. In retinal vascular occlusions of unexplained origin, antiphospholipid antibodies may play an important role in the pathogenesis. Detecting these antibodies in the serum of patients with retinal vascular occlusion helps determine the appropriate treatment with long-term oral anticoagulants.

Topics: Adult; Anti-Inflammatory Agents; Anticoagulants; Antiphospholipid Syndrome; Drug Therapy, Combination; Fluorescein Angiography; Fundus Oculi; Humans; Immunoglobulin G; Lupus Coagulation Inhibitor; Male; Phospholipids; Prednisone; Retinal Hemorrhage; Retinal Vein Occlusion; Visual Acuity; Warfarin

Topics: Humans; Prothrombin Time; Retinal Vein Occlusion; Retinal Vessels; Thrombosis; Warfarin