Do patients on anticoagulants (blood thinners) for heart problems require any precautions for a Lucentis (ranibizumab) eye injection?

Anticoagulation Management for Lucentis Eye Injections

Patients on anticoagulants for heart problems should continue their blood thinners without interruption when receiving Lucentis (ranibizumab) eye injections, as the risk of hemorrhagic complications is extremely low while stopping anticoagulation poses significant thromboembolic risk. 1, 2

Evidence-Based Recommendation

Continue all anticoagulation therapy through the procedure without dose adjustment or bridging, as multiple high-quality guidelines and studies demonstrate this is the safest approach. 1, 2, 3

Why Continuation is Recommended

• The American College of Chest Physicians explicitly classifies eye procedures (including intravitreal injections) as minor procedures where continuing warfarin around the time of the procedure is preferred over stopping it. 1

• The American College of Cardiology/American Heart Association guidelines state that eye surgery, particularly for cataracts or glaucoma, is usually associated with very little bleeding and is frequently performed without alterations to antithrombotic treatment. 1

• A large retrospective study of 3,106 intravitreal anti-VEGF injections (including Lucentis) found zero hemorrhagic complications (no choroidal hemorrhage, vitreous hemorrhage, or increased submacular hemorrhage) in patients on warfarin (548 injections), Plavix (523 injections), or aspirin (1,254 injections). 2

• Another study of 149 ranibizumab injections in anticoagulated patients with INR values ranging from 0.8-4.9 (average INR 2.32) found only minor subconjunctival hemorrhages in 17.4% of cases, with no intraocular hemorrhages or coagulation-related complications. 3

Specific Management by Anticoagulant Type

Warfarin (Coumadin)

• Continue at therapeutic dose without interruption. 1, 2, 3
• Check INR on the day of or day before injection to confirm therapeutic range (typically 2.0-3.0). 3
• Do NOT stop warfarin 5-6 days before the procedure, as this guideline applies only to major surgeries, not eye injections. 1

Direct Oral Anticoagulants (DOACs: apixaban, rivaroxaban, dabigatran, edoxaban)

• Continue at regular dose without interruption. 1
• No bridging therapy is needed due to their short half-lives. 1
• The "stop 2-3 half-lives before surgery" recommendation applies only to procedures with normal-to-high bleeding risk, which does NOT include intravitreal injections. 1

Antiplatelet Agents (aspirin, clopidogrel/Plavix)

• Continue all antiplatelet drugs without interruption. 1, 2
• The American College of Chest Physicians specifically recommends continuing antiplatelet drugs for minor eye procedures. 1
• Stopping antiplatelet therapy 7-10 days before procedure is recommended only for major surgeries, not eye injections. 1

What to Expect

Minor Complications (Acceptable and Common)

• Subconjunctival hemorrhage occurs in approximately 17% of anticoagulated patients receiving intravitreal injections. 3
• These are cosmetically concerning but clinically insignificant and resolve spontaneously within 1-2 weeks. 3

Serious Complications (Extremely Rare)

• Intraocular hemorrhage risk is essentially zero in properly anticoagulated patients. 2, 3
• The 95% confidence interval for hemorrhagic complications in the largest study was 0.0000-0.0088 for warfarin and 0.0000-0.0088 for Plavix, indicating extremely low risk. 2

Critical Pitfalls to Avoid

Never stop anticoagulation for intravitreal injections, as the thromboembolic risk of interrupting therapy far exceeds the minimal bleeding risk from the procedure. 2

• Stopping warfarin even for 3 days in a high-risk patient (mechanical valve with prior thromboembolism) carries a 0.08-0.16% risk of thromboembolism, which exceeds the near-zero risk of serious ocular hemorrhage. 1

• For patients with mechanical heart valves, atrial fibrillation, or recent stroke, the consequences of thromboembolism (stroke, valve thrombosis, death) are catastrophic compared to a subconjunctival hemorrhage. 1

Do not confuse intravitreal injections with intraocular surgery (vitrectomy, cataract surgery), as guidelines for major eye surgery do not apply to simple injections. 1

Day-of-Procedure Checklist

• Confirm patient took their usual anticoagulant dose that morning (do NOT skip). 2, 3
• For warfarin patients, verify INR is in therapeutic range (ideally checked within 24 hours). 3
• Counsel patient that minor subconjunctival bleeding may occur but is harmless. 3
• Use standard sterile injection technique with topical anesthesia. 2, 3
• Apply gentle pressure to injection site for 30-60 seconds after injection. 2, 3