Anticoagulation Management During Cataract Surgery
Patients should continue their anticoagulant therapy during cataract surgery without interruption. 1, 2
Evidence-Based Rationale
The American College of Chest Physicians (ACCP) provides clear guidance on this matter, specifically recommending continuation of vitamin K antagonists (like warfarin) during cataract surgery rather than interrupting therapy 1. This recommendation is based on the minimal bleeding risk associated with cataract surgery compared to the potential thromboembolic risks of discontinuing anticoagulation.
The 2014 ACC/AHA guidelines similarly state that "in some instances in which there is minimal to no risk of bleeding, such as cataract surgery or minor dermatologic procedures, it may be reasonable to continue anticoagulation perioperatively" 1.
European guidelines also support this approach, specifically noting that "in patients undergoing surgery with a low risk of serious bleeding, such as cataract surgery, no changes in oral anticoagulation therapy are needed" 1.
Management Approach for Different Anticoagulants
Vitamin K Antagonists (e.g., Warfarin)
- Continue warfarin therapy without interruption
- Ensure INR is within therapeutic range (ideally <3.0) 2
- No bridging therapy is required
Direct Oral Anticoagulants (DOACs)
- Continue DOACs without interruption 2
- If concerned about bleeding risk, consider timing surgery at trough levels (just before next scheduled dose) 2
- For apixaban and rivaroxaban, no specific interruption is required for cataract surgery as it's considered a low bleeding risk procedure 3, 4
Antiplatelet Therapy
- Continue aspirin and other antiplatelet medications during cataract surgery 1, 2
- For patients with recent coronary stent placement (within 6 weeks for bare metal stents or 6 months for drug-eluting stents), dual antiplatelet therapy should not be interrupted 2
Surgical Considerations
To minimize bleeding risk while maintaining anticoagulation:
- Use topical or intracameral anesthesia rather than injectable anesthesia 2, 5
- Consider clear corneal surgical approach 6
- Have appropriate hemostatic measures available during surgery
Potential Complications and Management
While continuing anticoagulation does increase the theoretical risk of bleeding complications, studies show these are typically minor and self-limiting:
- Most common complications include dot hyphemae or subconjunctival hemorrhages 7
- These rarely affect visual outcomes 7
- The risk of serious thromboembolic events from discontinuing anticoagulation outweighs the minimal bleeding risk 5, 8
Special Considerations
- For patients with mechanical heart valves or high-risk atrial fibrillation, continuation of anticoagulation is particularly important 2
- If INR is >3.0 in patients on warfarin, consider postponing surgery until INR is within therapeutic range 1
- For patients on multiple antithrombotic agents (e.g., triple therapy), consider consultation with the prescribing physician, but in most cases, continuation remains the safest approach
In summary, the evidence strongly supports continuing anticoagulation during cataract surgery, as the risk of thromboembolic events from discontinuation outweighs the minimal risk of clinically significant bleeding complications.