Case
An 81 year old female presents to the clinic with a 2 days history of a red eye. She says that two days ago, she awoke in the morning and noticed a red “blotch” on her left eye. Over the past 48 hours it has not improved. Her past ocular history is significant for blepharitis and dry eyes OU, as well as bilateral cataract surgery performed about 10 years ago. Her past medical history is significant for hypertension, dyslipidemia, gastroesophageal reflux disease, osteoporosis, and a stroke 3 years ago. Her medications include rabeprazole, risedronate,, hydrochlorothiazide, ramipril, lipitor, and warfarin. She has been stable on a dose of 5mg warfarin the last 6 months ago, and she tells you that a recent INR from 1 week ago was 2.6.
On exam, visual acuity is 6/9 and 6/7.5 in the right and left eyes, respectively. Anterior segment exam of the left eye is shown below. The rest of the eye exam is unremarkable. Blood pressure is noted to be 135/70.
What is the best management option for this patient?
a. Discontinue the warfarin:
Minor bleeding such as from a subconjunctival hemorrhage does not warrant stoppage of the warfarin.
b. Reassurance and work-up for a coagulopathy.
The subconjunctival hemorrhage is likely secondary to warfarin therapy. It is very unlikely for a patient to present with coagulopathy this late in life.
c. Tell her to double the dose of antihypertensive medications:
Not only is this option incorrect given the blood pressure is only 135/70- it is also inappropriate to give such advice to the patient.
d. Reassurance only