Correspondence

Retro-Orbital Hemorrhage after Thrombolysis for Acute Myocardial Infarction

N Engl J Med 2007; 357:1448-1449October 4, 2007

Article

To the Editor:

Thrombolytic therapy continues to be an effective treatment for acute myocardial infarction when emergency coronary angioplasty is not available.1,2 We describe a spontaneous retro-orbital hemorrhage after thrombolysis for acute myocardial infarction in a patient with no history of surgery or trauma.

A 44-year-old, previously healthy man presented with an acute ST-segment myocardial infarction. He received 10 units of reteplase followed by a second 10-unit bolus. After treatment, the electrocardiographic findings returned to baseline, and his chest pain resolved.

Two hours later, atrial fibrillation developed, and an infusion of amiodarone was started. The patient then went into ventricular fibrillation, and he underwent cardioversion. His sinus rhythm and cardiac output were restored immediately. At this time, orbital proptosis on the left side was noted. He was extremely confused. An urgent computed tomographic (CT) scan of the head did not show intracerebral hemorrhage but did show a retro-orbital hemorrhage (Figure 1Figure 1Sagittal Computed Tomographic Section of the Intraconal Retro-Orbital Hemorrhage and Proptosis of the Globe, Soon after Proptosis Was Noted.).

Treatment with clopidogrel, aspirin, and a heparin infusion was initiated, and the patient subsequently underwent coronary angioplasty with stenting. A follow-up CT scan of the head obtained 6 days later showed resolution of the hemorrhage. His visual function was not assessed for several days because of his critical condition.

Antithrombotic therapy was continued throughout the patient's hospital stay, and he was discharged while receiving warfarin, aspirin, and clopidogrel. His proptosis resolved, and 4 months after the hemorrhage, his corrected visual acuity was normal.

A large retro-orbital hemorrhage has been reported in a patient who received thrombolytic therapy 2 days after undergoing a peribulbar block for an extracapsular cataract extraction.3 The post-thrombolysis antithrombotic therapy was discontinued, and he had a lasting visual deficit.

A bilateral retro-orbital hemorrhage after thrombolysis for a pulmonary embolus in a patient with no history of surgery or trauma has also been described.4 The post-thrombolysis antithrombotic therapy was discontinued, and the patient's recovery of vision was excellent.

A literature review of the ocular hemorrhagic complications of thombolysis among 41,021 patients showed 12 cases of periorbital, subconjunctival, or intraocular hemorrhage.5 There were no cases of retro-orbital hemorrhage.

Retro-orbital hemorrhage is a rare complication of thrombolysis. In our patient, this complication resolved spontaneously. Any patient in whom visual disturbance, pain, or proptosis develops after thrombolysis should be evaluated for retro-orbital hemorrhage. After a hemorrhage, the cardioprotective benefits of anticlotting agents need to be weighed against the threat to the patient's sight. This case shows that with maximal anticlotting therapy, retro-orbital hemorrhage can resolve, with an excellent visual outcome.

Thomas S. Cunneen, M.B., B.S.
Nigel Morlet, M.B., B.S.
Royal Perth Hospital, Perth 6000, Australia
tomcunneen@hotmail.com

5 References

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   Cucherat M, Bonnefoy E, Tremeau G. Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction. Cochrane Database Syst Rev 2003;3:CD001560-CD001560
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2. 2

   Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996;28:1328-1428
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   Leong JK, Ghabrial R, McCluskey PJ, Mulligan S. Orbital haemorrhage complication following postoperative thrombolysis. Br J Ophthalmol 2003;87:655-656
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4. 4

   Ahmar W, Mason K, Harley N, Hogan C. An unusual complication of thrombolysis -- bilateral retro-orbital haematoma. Anaesth Intensive Care 2005;33:271-273
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5. 5

   Mahaffey KW, Granger CB, Toth CA, et al. Diabetic retinopathy should not be a contraindication to thrombolytic therapy for acute myocardial infarction: review of ocular hemorrhage incidence and location in the GUSTO-I trial. J Am Coll Cardiol 1997;30:1606-1610
   CrossRef | Web of Science | Medline