From the Guidelines
Cataract surgery is considered a low-risk procedure for cardiac complications, with a reported cardiac risk generally less than 1%. According to the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1, cataract surgery is associated with a very low risk of major adverse cardiac events (MACE). The guideline states that for patients with a low risk of perioperative MACE, further testing is not recommended.
Risk Stratification
The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines provide a risk stratification table that categorizes noncardiac surgeries based on their reported cardiac risk 1. Cataract surgery is classified as a low-risk procedure, along with other surgeries such as endoscopic procedures, superficial procedures, and breast surgery.
Cardiac Complications
While the risk of cardiac complications is low, patients with pre-existing heart conditions such as coronary artery disease, heart failure, arrhythmias, or recent cardiac events may still face higher risks during surgery. Common cardiac complications include arrhythmias, myocardial infarction, and heart failure exacerbation. To minimize these risks, patients should undergo thorough preoperative cardiac evaluation if they have heart disease or risk factors.
Perioperative Management
Medications like beta-blockers or statins should generally be continued through the perioperative period 1. Local anesthesia is typically preferred over general anesthesia for patients with cardiac concerns as it causes less cardiovascular stress. Blood pressure and heart rate monitoring during surgery helps detect early signs of cardiac complications. Most cataract surgeries are outpatient procedures lasting less than 30 minutes, which helps reduce cardiac stress compared to longer operations.
High-Risk Patients
Patients with significant cardiac disease may benefit from having their surgery performed in a hospital setting rather than an ambulatory surgery center to ensure immediate access to advanced cardiac care if needed. The Revised Cardiac Risk Index (RCRI) is a simple, validated, and accepted tool to assess perioperative risk of major cardiac complications, and it can be used to identify patients who may require more intensive monitoring and care 1.
From the Research
Cardiac Risks Associated with Cataract Surgery
- The cardiac risks associated with cataract (intraocular lens implantation) surgery include myocardial infarction or ischemia, with rates of 5.1/1000 surgeries among routine aspirin users and 7.6/1000 surgeries among routine warfarin users who continued their medication before surgery 2.
- The risk of stroke, transient ischemic attack (TIA), or deep vein thrombosis was found to be low, with rates of 1.5/1000 among those who did not use aspirin or warfarin and 3.8/1000 surgeries among routine users of aspirin and warfarin who continued their medication before surgery 2.
- The use of anticoagulant and antiplatelet therapy during cataract surgery has been found to be safe, with no significant increase in intraoperative or postoperative complications 3, 4.
- However, the discontinuation of anticoagulant and antiplatelet therapy before cataract surgery may increase the risk of thromboembolism 3, 5.
- The long-term incidence of cataract and cataract surgery has been found to be associated with the use of antihypertensive medications, including oral or topical beta-blockers, which had a borderline association with nuclear cataract and significantly predicted incident cataract surgery 6.
Management of Antiplatelet and Anticoagulant Therapy
- The management of antiplatelet and anticoagulant therapy during cataract surgery should be individualized, taking into account the patient's medical history and the risk of thromboembolic events 3, 5.
- Topical or intracameral anesthesia is preferred over anesthesia injected with needles, and aspirin can be safely continued in patients undergoing cataract surgery 3.
- Warfarin has been extensively studied, and the risk of hemorrhage associated with cataract surgery is low if the international normalized ratio is in the therapeutic range 3.
- A multi-disciplinary approach is recommended for complex cases, and additional studies should be performed to better characterize the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery 5.