What is the recommended management of aspirin and clopidogrel (Plavix) in patients undergoing cataract surgery?

Management of Aspirin and Clopidogrel During Cataract Surgery

For patients undergoing cataract surgery, aspirin should be continued throughout the perioperative period, while clopidogrel (Plavix) should be discontinued for 5 days before surgery if the thrombotic risk is not high. 1

Aspirin Management

• Aspirin can be safely continued during cataract surgery as the risk of significant hemorrhagic complications is minimal 1, 2
• Multiple studies have demonstrated that aspirin continuation does not significantly increase the risk of sight-threatening bleeding events during cataract surgery 3, 4
• While subconjunctival hemorrhage risk may be slightly higher with continued aspirin use (RR: 1.74), this is a benign, self-limiting complication that does not affect surgical outcomes 4
• Discontinuation of aspirin before cataract surgery may increase the risk of thromboembolic events without providing significant benefit in reducing surgical bleeding 5
• The risk of serious cardiovascular events (stroke, TIA, myocardial infarction) outweighs the minimal bleeding risk associated with aspirin continuation 2, 6

Clopidogrel Management

• For patients on clopidogrel without high thrombotic risk, discontinuation for 5 days before cataract surgery is recommended 1
• In patients with high thrombotic risk (recent coronary stent placement within 6-12 months, history of stent thrombosis, multiple stents, bifurcation stents, diabetes with stents), a multidisciplinary approach involving cardiology consultation is necessary 1
• For high-risk patients, maintaining aspirin while temporarily discontinuing clopidogrel for 5 days represents a reasonable compromise between bleeding and thrombotic risks 1
• Clopidogrel should be resumed as soon as possible after surgery, ideally within 24 hours 1

Special Considerations

• Topical or intracameral anesthesia is preferred over injectable anesthesia techniques to minimize bleeding risk 2
• Clear corneal phacoemulsification technique is advantageous in patients receiving antiplatelet therapy 3
• For patients with drug-eluting coronary stents placed within the past year, the decision to discontinue clopidogrel requires careful multidisciplinary assessment of individual thrombotic versus bleeding risks 1
• Patients with bare metal stents placed more than 1 month ago or drug-eluting stents placed more than 6-12 months ago generally have lower thrombotic risk and can safely discontinue clopidogrel 1

Algorithm for Decision Making

1. Assess thrombotic risk:

   • High risk: Recent stent (<6-12 months), history of stent thrombosis, multiple/complex stents, diabetes with stents
   • Moderate risk: Stable coronary disease with stents >12 months
   • Low risk: Primary prevention or stable disease without stents

2. For aspirin:

   • Continue aspirin regardless of thrombotic risk category 1, 2, 4

3. For clopidogrel:

   • High thrombotic risk: Obtain cardiology consultation; consider continuing if surgeon comfortable with technique 1
   • Moderate/Low thrombotic risk: Discontinue 5 days before surgery 1

4. Postoperative management:

   • Resume clopidogrel within 24 hours after surgery 1
   • Consider loading dose of 300mg when restarting clopidogrel 1

By following these guidelines, the risk of both thrombotic and hemorrhagic complications can be minimized during cataract surgery in patients on antiplatelet therapy.