The etiology of the hemorrhage was uncertain. It was confirmed that the patient was not on anticoagulation, though he was taking a daily aspirin. The patient underwent an emergent surgical drainage of the choroidals. A specimen was sent for cytology that was negative for malignancy. Post operatively an ultrasound indicated that the patient had a recurrence of kissing choroidals. On postoperative examination the patient had bright red blood behind his intraocular lens. The patient also developed extensive periocular hemorrhage that tracked subcutaneously down the right side of his face into his neck (Figure 2). Given the extent of the bleeding an INR was drawn and found to be 3.0. As the patient was not on anticoagulation, an investigation was initiated with the assistance of the hematology service.
A DIC panel indicated an elevated D-dimer of 5373 ug/L (normal 0-500ug/L), fibrinogen of 82 mg/dL (normal 210-440mg/dL) and fibrin split products >40 ug/dL (normal 0). These laboratory values fit the criteria for DIC. The patient had a normal platelet aggregation assay. During his hospital stay he was also diagnosed with a urinary tract infection. It was postulated that the patient may have had chronic DIC from a number of his underlying medical conditions. There are reports of chronic low grade DIC associated with abdominal aortic aneurysm as well as systemic infection such as urosepsis. In this case the hematology team thought that his urinary tract infection was the cause of DIC as other diagnostic tests were negative. He was treated with vitamin K 5 mg subcutaneously for 3 days and his UTI was aggressively treated with IV antibiotics. His INR by the end of his hospital stay was 1.17. His final vision was no light perception in his right eye.