Should Mycophenolate Mofetil (MMF) be stopped prior to eye surgery?

Management of Mycophenolate Mofetil (MMF) Prior to Eye Surgery

Mycophenolate mofetil (MMF) should generally be continued during eye surgery, particularly for minor ophthalmologic procedures such as cataract surgery, as the risk of rejection or disease flare outweighs the minimal bleeding risk.

Rationale for Continuing MMF

The American College of Chest Physicians guidelines recommend continuing systemic immunosuppressive medications during minor ophthalmologic procedures 1. While these guidelines specifically address anticoagulants, the same principle applies to immunosuppressants like MMF for several reasons:

• MMF is not associated with increased bleeding risk like anticoagulants
• Discontinuation risks immune-mediated rejection or disease flare
• Eye surgery is generally considered a low-bleeding risk procedure

Evidence Supporting MMF Continuation

Research demonstrates that MMF is beneficial in preventing graft rejection following high-risk keratoplasty, with one study showing 83% immune reaction-free graft survival in the MMF group versus 64.5% in the control group 2. Abrupt discontinuation could potentially compromise these benefits.

Type of Eye Surgery Considerations

Minor Ophthalmologic Procedures

• Cataract surgery: Continue MMF without interruption
• Iridotomy: Continue MMF without interruption
• Panretinal photocoagulation: Continue MMF without interruption

More Complex Procedures

• Corneal transplantation: Especially important to continue MMF as it significantly improves rejection-free graft survival 2
• Glaucoma surgery with MMC: No contraindication to continuing MMF alongside intraoperative mitomycin-C (MMC) 1

Special Considerations

Infection Risk

• MMF is an immunosuppressant that may theoretically increase infection risk
• Consider prophylactic topical antibiotics (e.g., ofloxacin 0.3% three times daily for 3 days before surgery) 3
• Monitor closely for signs of infection postoperatively

Wound Healing

• While MMF inhibits lymphocyte proliferation, there is no strong evidence that it significantly impairs wound healing in ophthalmologic procedures
• For procedures involving extensive tissue manipulation, discuss with the treating rheumatologist or transplant specialist

Algorithm for Decision-Making

1. Assess procedure type:

   • Minor procedure (cataract, iridotomy): Continue MMF
   • Major procedure (corneal transplant): Continue MMF (even more important)

2. Evaluate patient-specific factors:

   • Reason for MMF therapy (transplant rejection prevention, autoimmune disease)
   • Disease stability and risk of flare if MMF interrupted
   • History of rejection episodes

3. Consult with prescribing physician if:

   • Patient has active infection
   • Patient has poor wound healing from previous surgeries
   • Procedure involves extensive tissue manipulation

Common Pitfalls to Avoid

1. Unnecessary discontinuation: Stopping MMF can lead to disease flare or transplant rejection
2. Inadequate communication: Ensure ophthalmologist and prescribing physician (rheumatologist/transplant specialist) communicate about management
3. Failure to monitor: Even with continued MMF, monitor for infection and wound healing complications

In conclusion, the benefits of continuing MMF during eye surgery generally outweigh the risks, particularly for patients who depend on this medication for prevention of transplant rejection or control of autoimmune disease.