Xarelto Management for Cataract Surgery
For cataract surgery in patients with normal renal function, hold Xarelto (rivaroxaban) the night before the procedure—taking the last dose 1 day prior—as cataract surgery is a low bleeding risk procedure that does not require extended anticoagulation interruption. 1
Rationale for Minimal Interruption
Cataract surgery is classified as a low hemorrhagic risk procedure where surgical hemostasis can be readily achieved and topical or intracameral anesthesia (not needle-based) is typically used. 1, 2
The French Working Group on Perioperative Hemostasis (GIHP) explicitly categorizes procedures with low bleeding risk as requiring only overnight interruption of direct oral anticoagulants (DOACs) including rivaroxaban. 1
For once-daily evening dosing of Xarelto: Hold the dose the night before surgery (last dose taken 2 days before the procedure day). 1
For once-daily morning dosing of Xarelto: Hold the morning dose on the day before surgery (last dose taken on the morning of the day before the procedure). 3
Why Not Longer Interruption?
The evidence strongly supports that extended interruption is unnecessary and potentially harmful for low-risk procedures:
Studies demonstrate that continuing anticoagulation during cataract surgery results in minimal bleeding complications—primarily self-limiting dot hyphemae or subconjunctival hemorrhages with no compromise to visual acuity. 4
The risk of thromboembolic events (stroke, TIA, deep vein thrombosis) increases when anticoagulation is discontinued unnecessarily, with rates of 3.8/1000 surgeries among those continuing anticoagulation versus potential increased risk with prolonged interruption. 5
Bridging anticoagulation is NOT recommended for cataract surgery, as it increases hemorrhagic risk without reducing thrombotic events. 1
Resumption Protocol
Resume Xarelto at least 6 hours after the procedure once adequate hemostasis is confirmed and there are no ongoing bleeding concerns. 1
- For evening dosing regimens: Resume the evening of surgery day. 1
- For morning dosing regimens: Resume the next morning after surgery. 1
Critical Pitfalls to Avoid
Do not stop Xarelto 3 days before cataract surgery—this extended interruption is reserved for high bleeding risk procedures (e.g., intracranial neurosurgery, neuraxial anesthesia) and unnecessarily increases thrombotic risk for low-risk procedures like cataract surgery. 1
Avoid needle-based anesthesia (retrobulbar or peribulbar blocks) in anticoagulated patients; use topical or intracameral anesthesia instead to minimize bleeding risk. 2
Do not use bridging therapy with heparin or low-molecular-weight heparin, as this increases bleeding complications without benefit. 1
Verify renal function before surgery—while the standard 1-day interruption applies to normal renal function (CrCl >30 mL/min), patients with impaired renal function may require longer interruption periods due to slower drug clearance. 3