Should a person stop taking Plavix (clopidogrel) before undergoing cataract surgery?

Management of Clopidogrel (Plavix) for Cataract Surgery

Clopidogrel (Plavix) should be continued throughout the perioperative period for cataract surgery as the minimal bleeding risk is outweighed by the potential thromboembolic risks of discontinuation. 1

Rationale for Continuing Clopidogrel

Cataract surgery is classified as a minimal-bleed-risk procedure with a 30-day risk of major bleeding of approximately 0% 1. The American College of Chest Physicians (ACCP) specifically recommends continuing antiplatelet therapy throughout the perioperative period for cataract surgery 1.

The risks of discontinuing clopidogrel include:

• Increased risk of thromboembolic events, especially in patients with recent coronary stent placement
• Potential for rebound hypercoagulability
• Risk of stroke, TIA, or deep vein thrombosis (3.8/1000 surgeries among those who continue antiplatelet medications vs. 1/1000 among those who discontinue) 2

Special Considerations

For Patients with Coronary Stents

• Dual antiplatelet therapy should not be interrupted for patients with recent coronary stent placement (within 6 weeks for bare metal stents or 6-12 months for drug-eluting stents) 1
• The risk of stent thrombosis if antiplatelet therapy is discontinued outweighs the minimal bleeding risk of cataract surgery 3

Surgical Technique Modifications

• Topical or intracameral anesthesia is preferred over injectable anesthesia for patients on antiplatelet therapy 1, 4
• Phacoemulsification with a small corneal incision is preferred over extracapsular cataract extraction to minimize bleeding risk 5

Exceptions to Consider

While the general recommendation is to continue clopidogrel, there may be rare situations where temporary discontinuation might be considered:

• If the surgeon has specific concerns about excessive bleeding risk
• If surgery must be performed in the posterior chamber of the eye with higher bleeding risk 3

In these exceptional cases, if clopidogrel must be interrupted:

• Stop it 5 days before surgery (rather than the traditional 7-10 days) 1
• Resume within 24 hours after surgery to reduce thromboembolic risk 1

Management Algorithm

1. Assess patient's thromboembolic risk:

   • Recent coronary stent (< 6 months for drug-eluting, < 6 weeks for bare metal)
   • History of stroke/TIA
   • Atrial fibrillation with high CHA₂DS₂-VASc score

2. Evaluate surgical approach:

   • Standard cataract surgery with topical/intracameral anesthesia → Continue clopidogrel
   • Surgery involving posterior chamber with high bleeding risk → Consider temporary discontinuation only if absolutely necessary

3. If continuing clopidogrel (recommended for most patients):

   • No loading dose needed upon resumption
   • Ensure surgeon is aware of antiplatelet status
   • Monitor for minor bleeding during and after procedure

4. If temporary discontinuation is absolutely necessary:

   • Stop clopidogrel 5 days before surgery 1
   • Resume within 24 hours after surgery 1
   • Consider loading dose (300-600 mg) for rapid effect (within 12-15 hours) if high thromboembolic risk 1

The evidence strongly supports continuing clopidogrel for cataract surgery in most patients, as the thromboembolic risks of discontinuation outweigh the minimal bleeding risks of this procedure.