Is it okay to continue oral anticoagulation (anticoagulant therapy) prior to cataract surgery?

From the Guidelines

It is generally okay to continue oral anticoagulation prior to cataract surgery, as the potential cardiovascular or thromboembolic risks of stopping anticoagulation outweigh the small risk of bleeding complications during cataract surgery 1. Patients taking medications such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), or clopidogrel (Plavix) typically do not need to stop these medications before undergoing cataract surgery.

Key Considerations

• Modern cataract surgery is minimally invasive, with very small incisions that have minimal bleeding risk.
• The risk of bleeding complications during cataract surgery is low, and most bleeds are self-limiting, consisting of dot hyphemas or subconjunctival bleeds without compromised visual acuity 1.
• Informing the ophthalmologist about all medications being taken is crucial, as they may want to monitor INR levels if the patient is on warfarin to ensure they are within a therapeutic range (typically 2.0-3.0).
• In rare cases with specific risk factors or complex surgical plans, the ophthalmologist might recommend medication adjustments in consultation with the cardiologist or primary care physician.

Recommendations

• Continue taking anticoagulants as prescribed unless specifically instructed otherwise by healthcare providers.
• For patients undergoing minor surgical procedures, including cataract surgery, it is recommended not to interrupt oral anticoagulation, as the risk of bleeding is easily controllable 1.
• The 2018 European Heart Rhythm Association practical guide suggests not interrupting oral anticoagulation for most minor surgical procedures, including those where bleeding is easily controllable 1.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . TREATMENT DURING DENTISTRY AND SURGERY The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons and dentists.

The FDA drug label does not provide direct guidance on continuing oral anticoagulation prior to cataract surgery. However, it does provide guidance on managing anticoagulation during other surgical procedures.

• For apixaban, the label recommends discontinuing the medication at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding.
• For warfarin, the label suggests that some dental or surgical procedures may be performed without undue risk of hemorrhage if the PT/INR is maintained at the low end of the therapeutic range. It is essential to consider the benefits and risks of continuing or discontinuing anticoagulation therapy prior to cataract surgery on a case-by-case basis, taking into account the individual patient's condition and the specific procedure being performed 2 3.

From the Research

Oral Anticoagulation and Cataract Surgery

• The decision to continue oral anticoagulation prior to cataract surgery depends on the individual patient's risk of thromboembolism and bleeding 4, 5, 6, 7.
• Studies suggest that the risk of hemorrhage associated with cataract surgery is low if the international normalized ratio is in the therapeutic range for patients taking warfarin 4.
• For patients taking direct oral anticoagulants, the evidence is limited, but one study found no significant difference in the rate of intraoperative and postoperative bleeding between patients taking direct oral anticoagulants and those without anticoagulation 8.
• The perioperative handling of oral anticoagulant therapy differs according to the periprocedural bleeding risk, and patients requiring a procedure with a minor risk for bleeding may not need to pause their anticoagulant therapy 5, 6, 7.
• In patients with a high risk of thromboembolism, a more aggressive perioperative management strategy with bridging therapy may be considered 6, 7.

Bleeding Risk and Anticoagulation

• The risk of bleeding during cataract surgery is generally low, even for patients taking anticoagulant or antiplatelet drugs 4, 8.
• One study found that cataract surgery can be safely performed while continuing direct oral anticoagulation, with no significant difference in the rate of intraoperative and postoperative bleeding between patients taking direct oral anticoagulants and those without anticoagulation 8.
• However, the decision to continue oral anticoagulation should be made on a case-by-case basis, taking into account the individual patient's risk of thromboembolism and bleeding 4, 5, 6, 7.

Management of Anticoagulation

• The management of anticoagulation during the perioperative period should be individualized, taking into account the patient's risk of thromboembolism and bleeding, as well as the type of anticoagulant being used 5, 6, 7.
• Early communication between healthcare providers is essential for managing high-risk patients on anticoagulation/antiplatelet agents during the perioperative period 7.
• The use of bridging therapy may be considered in patients with a high risk of thromboembolism, but the decision to use bridging therapy should be made on a case-by-case basis 6, 7.