Spontaneous Medial Rectus Haematoma: A Sight-Threatening Complication of Warfarin Toxicity

TL;DR

A 77-year-old woman on warfarin developed a rare eye condition causing vision loss, which improved after treatment.

Contribution

Highlights a rare sight-threatening complication of warfarin toxicity involving spontaneous medial rectus haematoma.

Findings

Spontaneous medial rectus haematoma occurred in a patient on warfarin, causing acute eye symptoms and elevated IOP.

Emergency canthotomy and cantholysis were performed, but additional procedures were needed to manage persistent IOP.

Visual acuity improved over four months, though a relative afferent pupillary defect remained.

Abstract

This report highlights a rare instance of spontaneous medial rectus haematoma in a 77-year-old female, attributed to warfarin use, underscoring its clinical significance. The patient initially presented with acute right eye pain, peri-orbital swelling, and reduced vision. Examination revealed a tense globe and elevated intraocular pressure (IOP), prompting emergency lateral canthotomy and inferior cantholysis. However, despite the initial procedure, her IOP remained elevated, indicating direct pressure from the haematoma on the globe and necessitating additional upper and lower eyelid lateral cantholysis. Medical management was also initiated to control the IOP. Over four months, the patient's visual acuity improved significantly, although a relative afferent pupillary defect persisted. This case underscores the rarity of spontaneous medial rectus haematoma in anticoagulated patients and highlights the critical importance of vigilant international normalized ratio (INR) monitoring and timely intervention to reduce morbidity and the risk of vision loss.

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