There is variability in the management of ophthalmic patients on anti-thrombotic agents (antiplatelets and anticoagulants) during the peri-operative period. A survey carried out in a UK teaching hospital on a cohort of ophthalmologists showed majority were comfortable with antiplatelet management but there was variability in managing patients on warfarin and direct oral anticoagulants (DOACs); 40% were unaware of existing guidelines. We aim to review the recommendations in the literature with regards to managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. We reviewed incidences of complications, specifically, the haemorrhagic complications associated. Pubmed search was carried out on relevant keywords from January 2007 to August 2017. All relevant UK guidelines including the Royal College of Ophthalmologists and British Society of Haematology were reviewed. Literature recommendations for routine cataract surgery under topical or sub-Tenon’s anaesthesia would be to continue all anti-thrombotic agents. For sharp needle anaesthesia, avoidance of dual antiplatelet therapy was recommended and warfarin could be continued if INR within therapeutic range. Recommendations for surgeries in glaucoma, vitreo-retinal, oculoplastic and lacrimal; and strabismus are presented. No evidence was found for corneal surgery. Haemorrhagic complications are reported in all groups. Limitations of this review include the retrospective nature, lack of randomized control trials and the limited evidence regarding DOACs. It is important for ophthalmologists to be aware of and balance the risk of thromboembolic events and risks of haemorrhagic complications for ophthalmic surgery. A multi-disciplinary approach is recommended for complex cases.
对于眼科病人在围手术期使用抗血栓药物(抗血小板和抗凝血剂)的管理情况存在差异。英国一家教学医院对一些眼科医生进行的队列调查显示, 大多数人对抗血小板治疗感到满意, 但在华法林和直接口服抗凝血剂(DOAC)治疗患者方面存在差异;40%的人不知道现有的指导方案。 回顾文献中关于眼科手术围手术期抗血栓药物管理的建议。我们回顾了并发症的发生率, 特别是与出血相关并发症的发生情况. 我们从2007年1月至2017年8月对相关关键词在Pubmed进行了搜索, 对所有相关的英国指南, 包括英国皇家眼科学院和英国血液病学会的指南进行了回顾性分析。 文献建议在局部或Tenon囊下麻醉的常规白内障手术可继续使用所有抗血栓药物。对于尖锐针麻醉, 建议避免双重抗血小板治疗, 如果INR在治疗范围内, 可以继续使用华法林。关于在青光眼、玻璃体视网膜、眼角膜、泪腺手术以及斜视的药物使用情况的建议见表格。没有发现在角膜手术 (围手术期使用抗凝药物) 的证据。所有不同的组别均报告有出血并发症。 本综述的局限性包括回顾性、缺乏随机对照试验以及关于DOACs的证据有限。对于眼科医生来说, 了解和权衡血栓栓塞发生的风险与眼科手术出血并发症的风险是非常重要的。对于复杂性病例, 建议采用多学科会诊的方式 (处理).
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Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal surgery. Am J Ophthalmol. 2011;151:934–939.e3.
Keeling D, Tait RC, Watson H. British Committee of Standards for Haematology. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol. 2016;175:602–13.
Calenda E, Lamothe L, Genevois O, Cardon A, Muraine M. Peribulbar block in patients scheduled for eye procedures and treated with clopidogrel. J Anesth. 2012;26:779–82.
Passemard M, Koehrer P, Juniot A, Bron AM, Creuzot-Garcher C. Maintenance of anticoagulant and antiplatelet agents for patients undergoing peribulbar anesthesia and vitreoretinal surgery. Retina. 2012;32:1868–73.
Esparaz ES, Sobel RK. Perioperative management of anticoagulants and antiplatelet agents in oculoplastic surgery. Curr Opin Ophthalmol. 2015;26:422–8.
Ing E, Douketis J. New oral anticoagulants and oculoplastic surgery. Can J Ophthalmol. 2014;49:123–7.
Patel R, Charles S, Jalil A. Antiplatelets and anticoagulants in vitreoretinal surgery, with a special emphasis on novel anticoagulants: a national survey and review. Graefes Arch Clin Exp Ophthalmol. 2017;255:1275–85.
Kong KL, Khan J. Ophthalmic patients on antithrombotic drugs: a review and guide to perioperative management. Br J Ophthalmol. 2015;99:1025–30.
van Veen JJ, Makris M. Management of peri-operative anti-thrombotic therapy. Anaesthesia. 2015;70(Suppl 1):58-67–e21-3.
Lip GY, Durrani OM, Roldan V, Lip PL, Marin F, Reuser TQ. Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract. 2011;65:361–71.
Healey JS, Eikelboom J, Douketis J, Wallentin L, Oldgren J, Yang S, et al. RE-LY Investigators. Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial. Circulation. 2012;126:343–8.
Sun MT, Wood MK, Chan W, Selva D, Sanders P, Casson RJ, et al. Risk of intraocular bleeding with novel oral anticoagulants compared with warfarin: a systematic review and meta-analysis. JAMA Ophthalmol. 2017;135:864–70.
Alwitry A, King AJ, Vernon SA. Anticoagulation therapy in glaucoma surgery. Graefes Arch Clin Exp Ophthalmol. 2008;246:891–6.
Kiire CA, Mukherjee R, Ruparelia N, Keeling D, Prendergast B, Norris JH. Managing antiplatelet and anticoagulant drugs in patients undergoing elective ophthalmic surgery. Br J Ophthalmol. 2014;98:1320–4.
Mather SJ, Kong KL, Vohra SB. Loco-regional anaesthesia for ocular surgery: anticoagulant and antiplatelet drugs. Curr Anaesth & Crit Care. 2010;21:158–63.
The Royal College of Ophthalmologists. National Ophthalmology Database Audit. London:RCOphth. 2018. https://www.nodaudit.org.uk/u/docs/20/avusuryktz/NOD%20Audit%20Annual%20Report%202018.pdf. Accessed 23 Dec 2018.
National Institute for Health and Care Excellence. Cataracts in adults: management. Full guideline. London:NICE; 2017. https://www.nice.org.uk/guidance/ng77/resources/cataracts-in-adults-management-pdf-1837639266757. Accessed 23 Dec 2018.
Lee RM, Thompson JR, Eke T. Severe adverse events associated with local anaesthesia in cataract surgery: 1 year national survey of practice and complications in the UK. Br J Ophthalmol. 2016;100:772–6.
Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AK, et al. EPR User Group. The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications. Eye (Lond). 2009;23:10–6.
Kobayashi H. Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract surgery. J Cataract Refract Surg. 2010;36:1115–9.
Bonhomme F, Hafezi F, Boehlen F, Habre W. Management of antithrombotic therapies in patients scheduled for eye surgery. Eur J Anaesthesiol. 2013;30:449–54.
Jamula E, Anderson J, Douketis JD. Safety of continuing warfarin therapy during cataract surgery: a systematic review and meta-analysis. Thromb Res. 2009;124:292–9.
The Royal College of Ophthalmologists. Cataract surgery guidelines. London:RCOphth. 2010. https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-SCI-069-Cataract-Surgery-Guidelines-2010-SEPTEMBER-2010-1.pdf. Accessed 20 Jan 2018.
Batra R, Maino A, Ch’ng SW, Marsh IB. Perioperative management of anticoagulated patients having cataract surgery: National audit of current practice of members of the Royal College of Ophthalmologists. J Cataract Refract Surg. 2009;35:1815–20.
Blum RA, Lindfield D. Direct oral anticoagulant drugs (DOAC). J Cataract Refract Surg. 2016;42:171–2.
Balbino M, Boin P, Prata TS. Perioperative management of anticoagulant users scheduled for glaucoma surgery: a survey among the Brazilian Glaucoma Society members. Arq Bras Oftalmol. 2013;76:363–5.
Cobb CJ, Chakrabarti S, Chadha V, Sanders R. The effect of aspirin and warfarin therapy in trabeculectomy. Eye (Lond). 2007;21:598–603.
Law SK, Song BJ, Yu F, Kurbanyan K, Yang TA, Caprioli J. Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy. Am J Ophthalmol. 2008;145:736–46.
Kojima S, Inatani M, Shobayashi K, Haga A, Inoue T, Tanihara H. Risk factors for hyphema after trabeculectomy with mitomycin C. J Glaucoma. 2014;23:307–11.
Golan S, Levkovitch-Verbin H, Shemesh G, Kurtz S. Anterior chamber bleeding after laser peripheral iridotomy. JAMA Ophthalmol. 2013;131:626–9.
Chandra A, Xing W, Kadhim MR, Williamson TH. Suprachoroidal hemorrhage in pars plana vitrectomy: risk factors and outcomes over 10 years. Ophthalmology. 2014;121:311–7.
Brillat E, Rouberol F, Palombi K, Quesada JL, Bernheim D, Albaladejo P, et al. A case-control study to assess aspirin as a risk factor of bleeding in rhegmatogenous retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol. 2015;253:1899–905.
Ryan A, Saad T, Kirwan C, Keegan DJ, Acheson RW. Maintenance of perioperative antiplatelet and anticoagulant therapy for vitreoretinal surgery. Clin Exp Ophthalmol. 2013;41:387–95.
Brown JS, Mahmoud TH. Anticoagulation and clinically significant postoperative vitreous hemorrhage in diabetic vitrectomy. Retina. 2011;31:1983–7.
Fabinyi DC, O’Neill EC, Connell PP, Clark JB. Vitreous cavity haemorrhage post-vitrectomy for diabetic eye disease: the effect of perioperative anticoagulation and antiplatelet agents. Clin Exp Ophthalmol. 2011;39:878–84.
Kent TL, Custer PL. Bleeding complications in both anticoagulated and nonanticoagulated surgical patients. Ophthal Plast Reconstr Surg. 2013;29:113–7.
Ben Simon GJ, Cheung N, McNab AA. Delayed epistaxis in external dacryocystorhinostomy: rate and risk factors. Arch Otolaryngol Head Neck Surg. 2010;136:183–6.
Liu CY, Samimi DB, Tao JP. Hemorrhagic complications of rivaroxaban after eyelid surgery. Ophthal Plast Reconstr Surg. 2016;32:74.
Kemp PS, Larson SA, Drack AV. Strabismus surgery in patients receiving warfarin anticoagulation. J AAPOS. 2014;18:84–6.
Bandivadekar P, Gupta S, Sharma N. Intraoperative suprachoroidal hemorrhage after penetrating keratoplasty: case series and review of literature. Eye Contact Lens. 2016;42:206–10.
Park Y, Kim MH, Won JY, Kim HS, Park YH. Vitreoretinal complications after penetrating keratoplasty. Retina. 2016;36:2110–5.
Koenig SB. Delayed massive suprachoroidal hemorrhage after descemet stripping automated endothelial keratoplasty. Cornea. 2011;30:818–9.
Qian CX, Harissi-Dagher M. Delayed suprachoroidal haemorrhage following Boston Keratoprosthesis in two aniridic patients. Br J Ophthalmol. 2011;95:436–7.
Wong JS. Spontaneous suprachoroidal haemorrhage in a patient receiving low-molecular-weight heparin (fraxiparine) therapy. Aust N Z J Ophthalmol. 1999 Dec;27:433–4.
Yang SS, Fu AD, McDonald HR, Johnson RN, Ai E, Jumper JM. Massive spontaneous choroidal hemorrhage. Retina. 2003;23:139–44.
Crews JW, Price MO, Lautert J, Feng MT, Price FW Jr. Intraoperative hyphema in Descemet membrane endothelial keratoplasty alone or combined with phacoemulsification. J Cataract Refract Surg. 2018;44:198–201.
Matharu KS, Smith SV, Lee AG. Retrobulbar hemorrhage and prasugrel. Can J Ophthalmol. 2016;51:e189–e190.
Huebert I, Heinicke N, Kook D, Boost KA, Mille CV, Mayer WJ, et al. Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. J Cataract Refract Surg. 2015;41:2092–101.
Calenda E, Cardon-Guiton A, Genevois O, Gueudry J, Muraine M. Peribulbar block in 500 patients scheduled for eye procedures and treated with acetyl salicylic acid. Acta Anaesthesiol Taiwan. 2011;49:141–3.
Subbiah S, McGimpsey S, Best RM. Retrobulbar hemorrhage after sub-Tenon’s anesthesia. J Cataract Refract Surg. 2007;33:1651–2.
Kara-Junior N, Santhiago MR, Almeida HG, Raiza AC. Safety of warfarin therapy during cataract surgery under topical anesthesia. Arq Bras Oftalmol. 2015;78:173–4.
Barequet IS, Sachs D, Shenkman B, Priel A, Wasserzug Y, Budnik I, et al. Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg. 2011;37:1434–8.
Barequet IS, Sachs D, Priel A, Wasserzug Y, Martinowitz U, Moisseiev J, et al. Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment. Am J Ophthalmol. 2007;144:719–23.
Grand MG, Walia HS. Hemorrhagic risk of vitreoretinal surgery in patients maintained on novel oral anticoagulant therapy. Retina. 2016;36:299–304.
Chandra A, Jazayeri F, Williamson TH. Warfarin in vitreoretinal surgery: a case controlled series. Br J Ophthalmol. 2011;95:976–8.
Mason JO 3rd, Gupta SR, Compton CJ, Frederick PA, Neimkin MG, Hill ML, et al. Comparison of hemorrhagic complications of warfarin and clopidogrel bisulfate in 25-gauge vitrectomy versus a control group. Ophthalmology. 2011;118:543–7.
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This work has previously been presented at the Royal College of Ophthalmology Congress May 2018 (Liverpool) as a poster presentation.
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Makuloluwa, A.K., Tiew, S. & Briggs, M. Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye 33, 1044–1059 (2019). https://doi.org/10.1038/s41433-019-0382-6