Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review

Abstract

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.

摘要

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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Correspondence to A. K. Makuloluwa.

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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

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