Atrial Fibrillation and Fitness for Cataract Surgery
Yes, patients with atrial fibrillation can be deemed fit for cataract surgery, and anticoagulation should be continued without interruption through the perioperative period. 1
Preoperative Fitness Assessment
Atrial fibrillation itself is not a contraindication to cataract surgery. The key considerations are:
- Calculate the CHA₂DS₂-VASc score to determine thromboembolic risk: males with scores ≥2 or females with scores ≥3 require anticoagulation regardless of surgical timing 1, 2
- Assess current anticoagulation status and ensure therapeutic dosing 2
- Evaluate for hemodynamic stability and adequate rate control 1
Perioperative Anticoagulation Management
Continue anticoagulation without interruption for cataract surgery. This is critical because:
- Cataract surgery is classified as a low-bleeding-risk procedure where the benefits of continued anticoagulation outweigh bleeding risks 1
- For patients on DOACs (apixaban, rivaroxaban, edoxaban, dabigatran), continue therapy through the perioperative period without interruption 1, 2
- For patients on warfarin, continue with INR maintained at 2.0-3.0 2
- Interrupting anticoagulation for up to 1 week is reasonable only for procedures with significant bleeding risk - cataract surgery does not meet this threshold 2
Common Pitfall to Avoid
Never discontinue anticoagulation solely because surgery is planned. The stroke risk from stopping anticoagulation exceeds the minimal bleeding risk of cataract surgery. Guidelines explicitly state that anticoagulation can be interrupted for up to 1 week without heparin bridging only for procedures carrying significant bleeding risk 2, which does not apply to cataract surgery.
Rate Control Optimization
Ensure adequate rate control before surgery:
- Continue beta-blockers throughout the perioperative period in all patients without contraindication, as withdrawal increases risk of perioperative atrial fibrillation 1
- Beta-blockers are recommended for rate control in patients with any ejection fraction 1, 2
- Alternative agents (diltiazem, verapamil) can be used if LVEF >40% and beta-blockers are contraindicated 1, 2
Postoperative Management
Maintain the same anticoagulation strategy postoperatively:
- Continue anticoagulation indefinitely based on CHA₂DS₂-VASc score, regardless of whether the patient remains in sinus rhythm 1, 3, 2
- Anticoagulation should never be discontinued based on successful rhythm control or perceived return to sinus rhythm 3, 4
- Monitor for any new-onset hemodynamic instability, which would require electrical cardioversion 1
Risk Factor Optimization
Before clearing for surgery, optimize modifiable bleeding risk factors:
- Ensure hypertension is controlled 1
- Avoid NSAIDs perioperatively 1
- Correct any anemia 1
- Do not use bleeding risk scores to withhold anticoagulation - they should only guide optimization of modifiable factors 1, 2
Documentation for Fitness
When providing fitness clearance, document: