From the Guidelines
Intravitreal injections generally pose a low risk of significant bleeding for patients on anticoagulants, and most ophthalmologists do not recommend stopping these medications before the procedure. Common anticoagulants like aspirin, clopidogrel (Plavix), warfarin (Coumadin), and direct oral anticoagulants (DOACs) such as apixaban (Eliquis) or rivaroxaban (Xarelto) can typically be continued safely 1. The risk of minor subconjunctival hemorrhage (bleeding on the eye surface) is increased, but this is cosmetic and resolves without consequences. More serious complications like vitreous hemorrhage or retrobulbar hemorrhage are extremely rare (less than 0.1%) 1. The potential cardiovascular risks of stopping anticoagulation (stroke, heart attack, venous thromboembolism) generally outweigh the minimal bleeding risks from the injection. However, patients should always inform their ophthalmologist about all medications they're taking before the procedure, and individual risk assessments may be made in specific cases. The ophthalmologist will typically use antiseptic preparation and may apply pressure briefly after the injection to minimize bleeding risk.
Some key points to consider:
- The risk of bleeding is generally low, and the benefits of continuing anticoagulation therapy often outweigh the risks of bleeding 1.
- The use of antiseptic preparation and brief pressure application after the injection can help minimize bleeding risk 1.
- Patients should always inform their ophthalmologist about all medications they're taking before the procedure, and individual risk assessments may be made in specific cases.
- The potential cardiovascular risks of stopping anticoagulation should be carefully considered, as they may outweigh the minimal bleeding risks from the injection 1.
Overall, the current evidence suggests that intravitreal injections can be safely performed in patients on anticoagulant therapy, with minimal risk of significant bleeding complications. The most recent and highest quality study 1 supports the continuation of anticoagulation therapy in patients undergoing intravitreal injections, and this approach is generally recommended by ophthalmologists.
From the Research
Risk of Bleeding with Intravitreal Injections in Patients on Anticoagulant Therapy
- The risk of hemorrhagic complications in systemically anticoagulated patients receiving intravitreal injections is extremely low 2.
- Studies have shown that there were no hemorrhagic complications noted in patients on Coumadin, Plavix, or aspirin 2.
- However, another study found that anticoagulant use was associated with a higher risk of intraocular hemorrhage, but without serious consequences 3.
- The use of antiplatelet agents has increased in patients undergoing vitreoretinal surgery, but probably does not increase the risk of postoperative intraocular bleeding 3.
- A study suggested that aspirin should not be stopped prior to surgery, while warfarin may be stopped if the patient's thromboembolic risk is low 4.
- Another study found that intravitreal injections can be performed without cessation of oral anticoagulation or antiplatelet therapy, with small subconjunctival haemorrhages noted in 45% of the eyes 5.
Management of Anticoagulant Therapy
- There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk 6.
- Discontinuation of anticoagulant therapy with warfarin, heparin, and other anticoagulants prior to interventional techniques increases safety, with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors 6.
- Low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure 6.
- Antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed if thromboembolic risk is high 6.