Do you need to hold Eliquis (apixaban) before cataract surgery?

Eliquis Management for Cataract Surgery

You do not need to hold Eliquis (apixaban) before cataract surgery. Cataract surgery is classified as a low-bleeding-risk procedure, and observational evidence demonstrates no bleeding events when DOACs are continued through cataract surgery. 1

Evidence Supporting Continuation

• A 25-patient observational study specifically assessed DOAC continuation in patients undergoing cataract surgery and identified zero bleeding events. 1

• Cataract surgery (phacoemulsification) is described as a "largely avascular procedure" with an extremely low bleeding risk profile. 1

• The American College of Chest Physicians 2022 guidelines classify cataract surgery among minor ophthalmologic procedures where anticoagulation continuation is safe. 1

Comparison to Warfarin Data

• For warfarin (VKA) therapy, the 2022 CHEST guidelines explicitly recommend continuation around cataract surgery rather than interruption. 1

• Meta-analyses of warfarin continuation during cataract surgery showed bleeding rates of approximately 10%, but almost all bleeds were self-limiting (dot hyphemas or subconjunctival hemorrhages) with no patient experiencing compromised visual acuity. 1

• The 2012 CHEST guidelines similarly recommended continuing VKAs during cataract surgery. 1

Anesthesia Considerations

The critical caveat is anesthesia technique:

• Topical or sub-Tenon's anesthesia is strongly preferred and carries minimal bleeding risk even with full anticoagulation. 1

• Retrobulbar (intraconal) anesthesia poses significant concern due to the potential for retrobulbar hematoma, which can cause vision loss. 1

• If retrobulbar anesthesia is planned, consider holding Eliquis for 1 day (24 hours) before the procedure, as this is the recommended duration for low-to-moderate bleeding risk procedures. 1, 2

Practical Algorithm

For standard cataract surgery with topical/sub-Tenon's anesthesia:

• Continue Eliquis without interruption 1
• No bridging anticoagulation needed 1, 2

For cataract surgery requiring retrobulbar anesthesia:

• Hold Eliquis for 1 day (skip the dose the day before surgery) 1, 2
• Resume 6-24 hours postoperatively once hemostasis confirmed 2, 3

For complex retinal surgery or higher-risk ophthalmologic procedures:

• Hold Eliquis for 1 day before the procedure 1, 2
• This applies to procedures beyond simple cataract extraction 1

Common Pitfalls to Avoid

• Do not routinely hold Eliquis for standard cataract surgery – the evidence shows this is unnecessary and exposes patients to thromboembolic risk. 1

• Do not use bridging anticoagulation – this increases bleeding risk without reducing thrombotic events. 1, 2

• Do not ignore anesthesia technique – retrobulbar blocks carry higher bleeding risk than topical/sub-Tenon's approaches. 1

• Do not assume all eye surgeries are equal – more complex retinal procedures may warrant brief interruption even though simple cataract surgery does not. 1

Supporting Research Evidence

• A systematic review of 65,196 patients found that aspirin continuation increased only subconjunctival hemorrhage risk, with no increase in sight-threatening complications like hyphema, retrobulbar hemorrhage, or vitreous hemorrhage. 4

• A prospective cohort of 19,283 cataract surgeries showed that continuation of anticoagulants resulted in extremely low rates of serious complications, with minimal absolute risk differences. 5

• Multiple studies confirm that discontinuing anticoagulation before cataract surgery may increase thromboembolic risk without meaningful reduction in bleeding complications. 6, 7, 8