From the Guidelines
Patients on Coumadin (warfarin) typically do not need to discontinue their medication before cataract surgery. According to the most recent and highest quality study, continuing VKAs around the time of cataract surgery is suggested instead of other strategies 1. Most ophthalmologists prefer to perform cataract surgery while patients remain on their regular warfarin dosage, as long as the INR (International Normalized Ratio) is within the therapeutic range, usually between 2.0 and 3.0. The surgeon should be informed about the anticoagulant use before surgery, and a recent INR test (within a week of surgery) is often required to ensure the level is appropriate.
Key Considerations
- Cataract surgery is generally considered a low-bleeding-risk procedure that uses small incisions and is performed under local anesthesia.
- The risk of serious bleeding complications during cataract surgery is very low, while the risk of thromboembolic events from discontinuing anticoagulation can be significant for patients with conditions like atrial fibrillation, mechanical heart valves, or history of stroke.
- However, the final decision should always be made in consultation with both the ophthalmologist and the physician who prescribed the warfarin, as individual patient factors may occasionally warrant medication adjustments.
Additional Guidance
- The American College of Chest Physicians suggests continuing VKAs with coadministration of an oral prohemostatic agent or stopping VKAs 2 to 3 days before minor procedures, but for cataract surgery, continuing VKAs is recommended 1.
- Other studies, such as the European Heart Journal guidelines, provide additional guidance on anticoagulation management in non-cardiac surgery, but the most relevant and recent guidance for cataract surgery is provided by the American College of Chest Physicians 1.
From the Research
Cataract Surgery and Coumadin (Warfarin) Therapy
- The decision to continue or discontinue Coumadin (warfarin) therapy in patients undergoing cataract surgery is a complex one, requiring careful consideration of the risks and benefits 2, 3, 4.
- Studies have shown that the risk of hemorrhage associated with cataract surgery is low if the international normalized ratio (INR) is in the therapeutic range 2, 4.
- In fact, one study found that patients who continued warfarin therapy during cataract surgery had an increased risk of bleeding, but these bleeds were not clinically significant and did not affect visual acuity 3.
- Another study found that warfarin therapy did not need to be ceased perioperatively in patients undergoing cataract surgery, as the risk of thromboembolic phenomena was low 4.
Bridging Anticoagulation Therapy
- In some cases, bridging anticoagulation therapy with low-molecular-weight heparin (LMWH) may be necessary to protect patients against thromboembolism while they are off warfarin 5, 6.
- Studies have shown that LMWH is a safe and effective alternative to unfractionated heparin for perioperative anticoagulation in patients undergoing cataract surgery 5, 6.
- A standardized periprocedural anticoagulation regimen with LMWH has been shown to be associated with a low risk of thromboembolic and major bleeding complications in patients at increased risk for arterial thromboembolism 6.
Recommendations
- Based on the available evidence, it appears that patients on Coumadin (warfarin) therapy do not necessarily need to be taken off the medication before undergoing cataract surgery, as long as the INR is in the therapeutic range 2, 3, 4.
- However, the decision to continue or discontinue warfarin therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3, 4.