When should aspirin (acetylsalicylic acid) be stopped before eye surgery?

Aspirin Management Before Eye Surgery

For most eye surgeries, aspirin should be continued perioperatively, but for closed-space posterior chamber eye procedures (vitreoretinal surgery), aspirin should be discontinued 5 days before surgery. 1

Risk-Based Decision Algorithm

Continue Aspirin (Most Eye Surgeries)

• Cataract surgery: Aspirin can be safely continued without increased bleeding risk, particularly when using topical or intracameral anesthesia rather than needle-based blocks 2
• Anterior segment procedures: Continue aspirin as bleeding risk is minimal and manageable with local hemostatic measures 1
• Low bleeding-risk ophthalmic procedures: The thrombotic risk of stopping aspirin outweighs the minimal bleeding risk 1, 3

Stop Aspirin 5 Days Preoperatively (High-Risk Eye Surgeries)

• Posterior chamber eye surgery: Aspirin must be withdrawn 5 days before surgery due to the closed-space nature where even minor bleeding can cause severe complications 1
• Vitreoretinal surgery: While aspirin alone showed little effect on bleeding in one study 4, current guidelines classify this as surgery in a confined space requiring aspirin cessation 1
• Intramedullary spine surgery and neurosurgery: These closed-space procedures similarly require 5-day aspirin withdrawal 1, 3

Special Considerations for Patients with Coronary Stents

For patients with coronary stents undergoing eye surgery, the decision becomes more complex and requires weighing stent thrombosis risk against surgical bleeding risk:

• Drug-eluting stents (DES) placed <12 months ago: Ideally postpone elective surgery until 12 months post-stent placement; if surgery cannot be delayed, maintain aspirin even for posterior chamber procedures and accept increased bleeding risk 1
• Bare-metal stents (BMS) placed <30 days ago: Postpone elective surgery; if urgent, continue aspirin 1
• Stents placed beyond recommended dual antiplatelet therapy duration: For posterior chamber eye surgery, aspirin may be stopped 5 days preoperatively, but resume within 24 hours postoperatively 1, 5

Evidence Supporting This Approach

The 2025 Association of Anaesthetists guidelines explicitly state that aspirin should be discontinued 5 days before procedures "in a confined space (brain, posterior chamber of the eye, medullary canal)" 1. This recommendation balances the irreversible platelet inhibition caused by aspirin (requiring 5 days for adequate platelet turnover) against the catastrophic consequences of bleeding in closed anatomical spaces 1, 3.

For cataract surgery specifically, multiple studies demonstrate that aspirin continuation is safe, with no significant increase in hemorrhagic complications when therapeutic anticoagulation levels are maintained 2. The key distinction is that cataract surgery involves the anterior chamber, not the posterior chamber where vitreoretinal procedures occur 4, 2.

Common Pitfalls to Avoid

• Do not routinely stop aspirin for all eye surgeries: This outdated practice fails to distinguish between low-risk anterior segment procedures and high-risk posterior chamber surgery 1, 3
• Do not stop aspirin for 7-10 days: The evidence supports 5 days as sufficient for platelet function recovery 1
• Do not substitute heparin for aspirin in stented patients: Heparin does not provide adequate protection against stent thrombosis and increases perioperative bleeding risk 1, 3
• Do not delay restarting aspirin: Resume within 24 hours postoperatively when hemostasis is achieved, particularly in high-risk cardiovascular patients 5, 3

Practical Management Steps

1. Identify the specific eye procedure: Anterior chamber (continue aspirin) versus posterior chamber/vitreoretinal (stop 5 days before) 1
2. Assess cardiovascular risk: Document presence of coronary stents, recent acute coronary syndrome, or high thrombotic risk 1
3. For posterior chamber surgery requiring aspirin cessation: Coordinate with cardiology for patients with recent stents; consider postponing elective surgery if within high-risk stent period 1
4. Resume aspirin promptly: Restart within 24 hours after surgery once adequate hemostasis achieved 5, 3