Eye Injections on Anticoagulants
Patients on anticoagulants can safely continue their anticoagulation therapy during minor ophthalmologic procedures, including eye injections, without interruption. 1
Evidence-Based Recommendation
The 2022 American College of Chest Physicians guidelines explicitly recommend continuing antiplatelet drugs (aspirin or P2Y12 inhibitors) throughout minor ophthalmologic procedures rather than stopping them beforehand. 1 This same principle applies to anticoagulants, as ophthalmologic procedures are classified as minimal bleeding risk interventions. 1
Key Supporting Evidence
Prospective cohort studies in patients undergoing phacoemulsification (cataract) surgery demonstrated a very low (<1%) risk of major bleeding with perioperative aspirin continuation. 1
Randomized trial data from 42 patients having eyelid surgery showed no significant increase in bleeding or thromboembolic outcomes when aspirin was continued. 1
Warfarin continuation during cataract surgery has been extensively studied, showing low hemorrhage risk when the INR remains in therapeutic range. 2
Clinical Management Algorithm
For Warfarin Patients:
- Continue warfarin at the usual maintenance dose without interruption. 1
- Verify INR is within therapeutic range (typically 2.0-3.0) before the procedure. 2
- No bridging anticoagulation is needed for these minimal-risk procedures. 1
For Direct Oral Anticoagulants (DOACs):
- Continue the DOAC without dose adjustment or interruption. 1
- Ensure the patient takes their medication on the regular schedule. 3
For Dual Antiplatelet Therapy:
- Continue aspirin throughout the procedure. 1
- The P2Y12 inhibitor can be interrupted if desired, though continuation is also acceptable. 1
Important Caveats
High-risk ophthalmologic procedures such as vitreoretinal surgery or reconstructive eye surgery are exceptions to this rule and may require anticoagulation interruption with consideration of bridging therapy. 1 However, standard intravitreal injections, cataract surgery, and routine eye procedures do not fall into this category.
Anesthesia technique matters: Topical or intracameral anesthesia is strongly preferred over needle-based retrobulbar or peribulbar blocks in anticoagulated patients to minimize bleeding risk. 2
Bleeding complications, while rare, can occur with DOACs and include submacular hemorrhage, vitreous hemorrhage, and hyphema. 4 However, the absolute risk remains low enough that routine continuation is justified given the thrombotic risk of interruption.
Risk-Benefit Analysis
The thrombotic risk of interrupting anticoagulation substantially outweighs the minimal bleeding risk associated with most eye injections. 2 Discontinuing anticoagulants before cataract or injection procedures may increase the risk of stroke, systemic embolism, or venous thromboembolism. 2
For patients at high thrombotic risk (mechanical heart valves, recent stroke/TIA within 3 months, CHA₂DS₂-VASc score ≥4, or VTE within 3 months), the imperative to continue anticoagulation is even stronger. 1