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Sir,

Spontaneous suprachoroidal haemorrhage occurs in age-related macular degeneration (ARMD) and anticoagulants are a recognised risk factor.1 In highly myopic patients, suprachoroidal haemorrhage occurs in situations when the fragile vasculature is put under additional stress such as in cataract surgery.2 There have been no reports of large spontaneous suprachoroidal haemorrhage in myopic patients. The role of anticoagulants as a contributing factor in these patients is unknown.

Case report

A 78-year-old lady attended eye casualty complaining of a 2-day history of mild discomfort in the left eye, followed by an episode of complete loss of vision in the eye, which came back to normal after 1 h. The eye now felt tender and she complained of a visual disturbance ‘like bubbles’ in the temporal periphery of the left eye. She had had two similar episodes over the past 2 years, but had not sought medical help on those occasions.

She was hypertensive, on bendrofluazide, enalapril and 75 mg of aspirin, and a nonsmoker.

She had been seen in eye clinic since 1954 with high myopia (−11.00/−2.00 × 63 right; −9.00/−1.25 × 104 left). Her axial lengths were 31.18 mm right and 29.14 mm left. Her visual acuity since 1983 in the right eye was hand movements secondary to myopic macular degeneration, choroidal neovascular membrane and a dense brunescent cataract. The left eye's visual acuity was 6/12. The intraocular pressures were 17 mmHg in the right and 20 mmHg in the left. There was a nuclear sclerotic cataract in the left eye and no signs of haemorrhage in the vitreous. On fundoscopy she had extensive peripapillary atrophy and a myopic looking disc. There were multiple areas of chorioretinal atrophy. Anteriorly, encompassing 360° was a raised choroidal mass and there was extensive subretinal haemorrhage (Figure 1). B-Scan ultrasound confirmed the characteristics of a choroidal haemorrhage (Figure 2).

Figure 1
figure 1

Fundus colour photograph of the left eye showing extensive subretinal haemorrhage, which encompassed 360°.

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Figure 2
figure 2

B-Scan ultrasound of the left eye confirming choroidal haemorrhage.

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Routine blood tests including a clotting screen were entirely normal. She subsequently underwent fluorescein angiogram once the haemorrhage had resolved, which excluded a subretinal neovascular membrane or telangiectasia.

After 1 month, her visual symptoms and haemorrhages had resolved spontaneously, visual acuity remained 6/12.

Comment

Following an exhaustive search of Medline/Pubmed and Ovid databases, large spontaneous suprachoroidal haemorrhage associated with high myopia has not, to our knowledge, been published previously in the literature. Myopia is a risk factor for suprachoroidal haemorrhage in cataract surgery because the longer axial length causes increased choroidal vascular fragility.2 This patient was also hypertensive and it has been widely reported that hypertension, arteriosclerosis and advanced age are systemic risk factors for suprachoroidal haemorrhage in a surgical setting,3 but the association with these risk factors in spontaneous haemorrhage is unknown. This patient may also have had ARMD, which may not have been apparent on the fluorescein angiogram. A review of ARMD complicated by massive haemorrhage reported on subretinal and vitreous haemorrhage only,4 as suprachoroidal haemorrhage in ARMD appears to be relatively rare. On balance, therefore, we believe that although these other factors may have contributed to the haemorrhage, myopia was the primary cause.

This patient was also on low-dose aspirin and this may have contributed to the extent of her haemorrhage.5 The risk of spontaneous suprachoroidal haemorrhage in association with myopia and the additional risk of anticlotting agents have not been studied. Subconjunctival haemorrhage, spontaneous hyphema, subretinal or vitreous haemorrhage and suprachoroidal haemorrhage have been described with anticoagulation.6 One case controlled retrospective study of 50 patients with ARMD showed an odds ratio of 11.6 that a patient with a massive intraorbital haemorrhage would also be on anticoagulants (warfarin or aspirin). In another study, the antiplatelet odds ratio (aspirin) was smaller at 2.1.7

Whether these risks can be extrapolated to myopic eyes is unknown. This rare case illustrates how high myopia associated with choroidal vasculature fragility exacerbated by hypertension could cause spontaneous haemorrhage. This was further aggravated by the presence of aspirin in this patient.