Should acetylsalicylic acid (aspirin) and clopidogrel be stopped prior to routine cataract extraction (phacoemulsification)?

Antiplatelet Management for Cataract Surgery

Both aspirin and clopidogrel should be continued during routine cataract surgery (phacoemulsification), as the risk of sight-threatening bleeding is negligible while discontinuation poses significant cardiovascular risks. 1, 2

Evidence-Based Recommendation

The American College of Chest Physicians explicitly recommends continuing aspirin for patients undergoing cataract surgery rather than stopping it 7-10 days before the procedure (Grade 2C). 1 This recommendation is based on prospective cohort studies demonstrating a very low (<1%) incidence of major bleeding with perioperative aspirin continuation. 1

• Cataract surgery is classified as a low-risk bleeding procedure where antiplatelet therapy should not be interrupted. 2
• The incidence of cardiovascular events was actually similar or lower in patients who continued aspirin (0.20%) versus those who interrupted it (0.65%). 1

Management of Dual Antiplatelet Therapy (DAPT)

For patients on both aspirin and clopidogrel, both medications should be continued without interruption. 2 This is particularly critical for patients with recent coronary stent placement.

• A 43-patient retrospective study of patients on combined aspirin and clopidogrel found no bleeding episodes with continuation of dual antiplatelet therapy during dental procedures, and this principle extends to cataract surgery. 1
• A prospective study of 38 patients on dual antiplatelet therapy undergoing phacoemulsification found no significant difference in hemorrhagic complications compared to controls, with no cases of anterior chamber hemorrhage, vitreous hemorrhage, or suprachoroidal hemorrhage. 3
• The American College of Cardiology explicitly lists cataract surgery as safe even with DAPT continuation. 2

Surgical Technique Considerations

Use topical anesthesia with a clear corneal incision approach to minimize bleeding risk. 2, 4, 5

• A study of 51 eyes in patients on combined warfarin and antiplatelet therapy demonstrated no hemorrhagic complications when using topical needle-free anesthesia with clear corneal incision. 4
• Avoid retrobulbar or peribulbar needle-based anesthesia in anticoagulated patients, as this increases bleeding risk. 6

Expected Bleeding Outcomes

The only statistically significant bleeding complication with aspirin continuation is subconjunctival hemorrhage, which is not sight-threatening. 7

• A meta-analysis of 65,196 patients showed aspirin continuation increased subconjunctival hemorrhage risk (RR: 1.74,95% CI: 1.22-2.50), but did not increase risk of hyphema, retrobulbar hemorrhage, vitreous hemorrhage, or other serious complications. 7
• A prospective study of 61 patients found no intraoperative bleeding or hemorrhagic complications at 1-week follow-up in patients continuing aspirin. 5

Critical Pitfalls to Avoid

Never discontinue antiplatelet therapy for cataract surgery based on routine bleeding concerns. 1, 2

• Discontinuing aspirin or clopidogrel increases the risk of myocardial infarction, stroke, stent thrombosis, and death—risks that far outweigh the minimal bleeding risk of cataract surgery. 1
• For patients with coronary stents, premature discontinuation of thienopyridines has resulted in fatal stent thrombosis in multiple case series. 1
• The American Heart Association emphasizes that many procedures, including cataract surgery, can be performed safely without interrupting antiplatelet therapy, and local hemostatic measures are sufficient to manage any minor bleeding. 1

Do not routinely order platelet function assays to guide management, as they do not improve outcomes. 2