Can a patient with anemia be cleared for eye surgery?

Preoperative Anemia and Eye Surgery Clearance

A patient with anemia should not be automatically cleared for eye surgery; anemia must first be investigated, the underlying cause identified, and ideally corrected preoperatively to reduce perioperative morbidity, mortality, and transfusion requirements. 1

Why Anemia Matters for Surgical Clearance

Preoperative anemia is associated with increased postoperative complications, higher blood transfusion rates, and increased mortality across all surgical procedures. 1 While the available guidelines focus primarily on major abdominal, pelvic, and orthopedic surgeries, the fundamental principle applies universally: anemia is a serious and treatable medical condition that should be optimized before elective surgery. 1

• Anemia prevalence in surgical patients ranges from 30-40%, making it a common perioperative risk factor. 2, 3
• Even for procedures with expected blood loss >500 ml, patients with hemoglobin <130 g/L should undergo optimization. 2
• The increased morbidity and mortality associated with anemia persists regardless of surgical type. 4, 5, 6

Preoperative Evaluation Algorithm

Timing of Assessment

• Measure hemoglobin ideally 28 days before scheduled surgery to allow sufficient time for evaluation and treatment. 1, 7
• This lead time provides opportunity to investigate the cause, initiate treatment, and reassess response before proceeding. 1

Laboratory Workup Required

All anemic patients require comprehensive laboratory testing to identify the underlying cause before surgery: 1, 7

• Serum ferritin and transferrin saturation (TSAT) to diagnose iron deficiency (ferritin <30 μg/L indicates low iron stores; TSAT <16-20% indicates insufficient circulating iron). 7, 8
• Vitamin B12 and folate levels to screen for nutritional deficiencies. 1, 7
• Serum creatinine and GFR to evaluate for chronic kidney disease. 1, 7
• Complete blood count with indices to characterize the anemia type. 7

Critical Pitfall to Avoid

• Ferritin is an acute phase reactant and can be falsely normal or elevated during inflammation despite true iron deficiency. 7, 8
• Ferritin >150 μg/L essentially excludes absolute iron deficiency even with concurrent inflammation. 8

Treatment Before Surgery

Iron Deficiency Anemia

For confirmed iron deficiency, treatment choice depends on timing and severity: 7

• Oral iron (40-60 mg elemental iron daily) if surgery is more than 6-8 weeks away. 7
• Intravenous iron is preferred for moderate-to-severe anemia with surgery within 2-3 weeks, as it more effectively restores hemoglobin than oral iron. 1, 7
• IV iron supplementation decreases blood transfusion requirements by 16% without increased adverse effects. 1

Nutritional Deficiencies

• Treat vitamin B12 or folate deficiency with appropriate supplementation. 1, 7

Anemia of Chronic Disease or Renal Insufficiency

• Consider erythropoiesis-stimulating agents (ESAs) with concurrent IV iron when nutritional deficiencies have been ruled out or corrected. 1, 7
• Refer to nephrology for chronic kidney disease management. 7

Blood Transfusion

• Avoid preoperative blood transfusion as it carries significant short- and long-term complications and is independently associated with worse outcomes. 1

Decision to Proceed with Surgery

For Elective Eye Surgery

The decision framework should follow this algorithm:

1. If anemia is detected ≥28 days before surgery: Investigate cause, initiate appropriate treatment, and delay surgery until hemoglobin is optimized toward normal WHO range. 1, 7

2. If anemia is detected close to surgical date: Consider delaying elective surgery if newly diagnosed anemia requires evaluation. 7

3. Target hemoglobin should be within normal WHO range (men: ≥130 g/L; women: ≥120 g/L) before proceeding with elective surgery. 1

Special Considerations for Eye Surgery

While the provided guidelines address major surgeries with significant blood loss, eye surgery typically involves minimal blood loss. However, the principle remains: anemia should be viewed as a serious medical condition requiring investigation and treatment rather than simply an abnormal laboratory value. 1

• The underlying cause of anemia may represent undiagnosed serious pathology (e.g., gastrointestinal malignancy in iron deficiency). 7, 8
• Correcting anemia preoperatively improves postoperative physical rehabilitation and quality of life. 7
• Even minor procedures carry increased risk in anemic patients due to reduced oxygen-carrying capacity and associated comorbidities. 4, 5, 6

Clinical Benefits of Preoperative Optimization

Treating preoperative anemia appropriately provides multiple benefits: 7

• Reduces perioperative morbidity and mortality
• Decreases red blood cell transfusion requirements
• Shortens hospital length of stay
• Reduces postoperative complications
• Improves postoperative physical rehabilitation and quality of life