Is a patient with a prolonged partial thromboplastin time (PTT) on Plavix (clopidogrel), Eliquis (apixaban), and Aspirin (ASA) a suitable candidate for cataract surgery?

Management of Anticoagulation and Antiplatelet Therapy for Cataract Surgery

The patient with a PTT of 23 who is on Plavix (clopidogrel), Eliquis (apixaban), and ASA (aspirin) can safely proceed with cataract surgery without discontinuing these medications.

Evidence-Based Rationale

The American College of Chest Physicians (ACCP) provides clear guidance on this issue:

• For patients undergoing cataract surgery who are receiving anticoagulants or antiplatelet therapy, the ACCP recommends continuing these medications throughout the perioperative period 1, 2.
• Specifically, for patients on antiplatelet drugs (ASA or P2Y12 inhibitors like clopidogrel) undergoing minor ophthalmologic procedures, continuing the antiplatelet drug is recommended over stopping it before the procedure 1.

Management Algorithm for Anticoagulation in Cataract Surgery

1. For aspirin (ASA):

   • Continue aspirin throughout the perioperative period 1, 2.
   • The risk of bleeding during cataract surgery with continued aspirin use is minimal and rarely clinically significant 3, 4.

2. For clopidogrel (Plavix):

   • Continue clopidogrel for cataract surgery 1, 2.
   • For patients on dual antiplatelet therapy, the ACCP suggests continuing ASA and potentially interrupting the P2Y12 inhibitor if there are significant bleeding concerns 1.
   • However, for minor ophthalmologic procedures like cataract surgery, both can typically be continued 1.

3. For apixaban (Eliquis):

   • Continue apixaban during cataract surgery 2.
   • The ACCP guidelines support continuing oral anticoagulation for minor procedures like cataract surgery, and this recommendation extends to direct oral anticoagulants (DOACs) like apixaban 2.

Special Considerations

• Anesthesia technique: Topical or intracameral anesthesia is preferred over injectable anesthesia for patients on anticoagulants/antiplatelets 2, 3.

• Surgical approach: Clear corneal phacoemulsification is advantageous in patients receiving antiplatelet therapy 4.

• PTT value: A PTT of 23 is actually within normal range (typically 25-35 seconds) or slightly low, and does not indicate excessive anticoagulation. This supports proceeding with surgery.

• Bleeding risk: While there is a theoretically increased risk of bleeding with continued anticoagulation, studies show that such bleeding events during cataract surgery are typically minor (subconjunctival hemorrhages or dot hyphemae) and self-limiting, without impact on visual outcomes 5.

Potential Risks of Discontinuation

The risks of discontinuing anticoagulation/antiplatelet therapy include:

• Increased risk of thromboembolic events, which can have serious consequences 6.
• For patients with coronary stents, discontinuation of dual antiplatelet therapy can lead to stent thrombosis, particularly if stents were placed recently 1, 2.

Conclusion

The evidence strongly supports continuing all three medications (Plavix, Eliquis, and ASA) during cataract surgery. The minimal bleeding risk is outweighed by the potential thromboembolic risks of discontinuation. The surgeon should be informed of the patient's medication regimen, and appropriate surgical techniques (topical anesthesia, clear corneal approach) should be employed to minimize any bleeding risk.