Acute Angle Closure Glaucoma Secondary to Suprachoroidal Hemorrhage Triggered by Valsalva Maneuver: A Rare Case

Spontaneous suprachoroidal hemorrhage is a rare ophthalmic emergency, typically associated with ocular surgery or trauma. However, it can occur spontaneously in anticoagulated elderly patients after a sudden rise in venous pressure, such as during a Valsalva maneuver. We report a rare case of acute angle closure glaucoma secondary to suprachoroidal hemorrhage triggered by severe vomiting in an anticoagulated patient. An 84-year-old male with atrial fibrillation on apixaban was hospitalized for biliary colic. Following repeated vomiting episodes, he experienced sudden, painful vision loss in the left eye. Examination revealed corneal edema, a shallow anterior chamber, a mid-dilated non-reactive pupil, and markedly elevated intraocular pressure (IOP) of 50 mmHg. Imaging demonstrated dislocation of the intraocular lens and angle closure, while B-scan ultrasonography and infrared image confirmed bilateral dome-shaped choroidal elevations consistent with suprachoroidal hemorrhage. Maximal topical and systemic IOP-lowering therapy was initiated. Due to significant comorbidities and high thromboembolic risk, anticoagulation was continued, and surgical intervention was not pursued. The patient's pain was gradually relieved, but visual function did not recover. This case highlights a rare but vision-threatening complication of spontaneous suprachoroidal hemorrhage induced by a Valsalva maneuver in a high-risk patient. In this case, vomiting likely caused a sudden rise in intra-abdominal pressure, leading to rupture of fragile choroidal vessels. The resulting anterior displacement of intraocular structures caused secondary angle closure glaucoma. Prompt diagnosis with B-scan ultrasonography and aggressive medical management are critical, though visual prognosis remains poor in such cases. Surgical drainage is considered in select patients but was contraindicated here. Clinicians should maintain a high index of suspicion for suprachoroidal hemorrhage as a potential cause of acute angle closure in elderly, anticoagulated patients presenting with sudden painful vision loss. Timely diagnosis with B-scan and careful individualized management are crucial, particularly when surgical options are limited by systemic risk factors.