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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Sweitzer B, Rajan N, Schell D, Gayer S, Eckert S, Joshi GP. Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2021; 133:1431-1436. [PMID: 34784329 DOI: 10.1213/ane.0000000000005652] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.
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Affiliation(s)
- BobbieJean Sweitzer
- From the Departments of Anesthesiology and Surgical Services, Inova Health System, Falls Church, Virginia
| | - Niraja Rajan
- Hershey Outpatient Surgery Center, Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Dawn Schell
- Cole Eye and Anesthesiology Institutes, Cleveland Clinic, Cleveland, Ohio, Cleveland, Ohio
| | - Steven Gayer
- Department of Anesthesiology, University of Miami's Miller School of Medicine, Miami, Florida
| | - Stan Eckert
- Regional Medical Director Ambulatory Surgery Division, Hospital Corporation of America, Austin, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Ryan A, Sadiq O, Tolley S, Wijetilleka S, Williams GS. Patient preference and pain-reported outcomes for topical versus subtenon anesthetic for cataract surgery. Saudi J Ophthalmol 2021; 34:290-293. [PMID: 34527874 PMCID: PMC8409353 DOI: 10.4103/1319-4534.322609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/07/2020] [Accepted: 10/16/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE: Cataract extraction and lens implantation is the most common surgical procedure performed worldwide, with surgeons opting for either a topical or a subtenon anesthetic in majority of cases. While complication rates and pain scores have been previously examined in a bid to determine which modality was better, patients who have had both eyes operated upon under different techniques have never previously been asked which method they prefer. We undertook this study to fill in this crucial gap in our knowledge. METHODS: This is a retrospective study of patients who have undergone bilateral cataract surgery with one eye operated on with topical anesthesia and the other eye with subtenon anesthesia. Patients were identified who had had surgery undertaken in the previous 6 months at Singleton Hospital, Swansea, where both eyes had been operated upon using different anesthetic techniques. Telephone interviews with these patients were performed and their pain scores recorded on a scale from 0 (no pain) to 10 (severe pain) for both eyes, with the patients then being asked which the method of anesthetic they preferred. Statistical analysis of pain scores was compared using Wilcoxon rank-sum testing. RESULTS: One hundred and fifty-two patients in total were identified. One hundred and forty-one of the applicable patients participated in the study. Of these, 78 patients received topical anesthesia for their first operation and 63 had subtenon block for their first operation. The mean pain scores reported for surgery with topical anesthesia and subtenon block were 2.30 and 1.38, respectively. The pain data were analyzed using a Wilcoxon signed-rank test, returning a z-score of 4.038. This result therefore suggests that patients experience statistically significantly less pain from cataract surgery when given a subtenon block. Patients expressed a preference for subtenon anesthesia, with 70% preferring subtenon block, 23% preferring topical anesthesia, and 7% having no preference. CONCLUSIONS: Patients report less pain with subtenon anesthesia compared with topical anesthesia in cataract surgery, where both eyes were operated upon with different anesthetic techniques. This is the first study in which patients who have had both anesthetic techniques performed independently for cataract surgery have had their pain scores reported and statistically analyzed.
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Affiliation(s)
- Adam Ryan
- Department of Ophthalmology, Singlwton Hospital, Swansea, Wales, UK
| | - Omair Sadiq
- Department of Ophthalmology, Singlwton Hospital, Swansea, Wales, UK
| | - Suzanne Tolley
- Department of Ophthalmology, Singlwton Hospital, Swansea, Wales, UK
| | | | - Gwyn S Williams
- Department of Ophthalmology, Singleton Hospital, Sketty Lane, Swansea, Wales, UK
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Barequet IS, Zehavi-Dorin T, Bourla N, Tamarin I, Moisseiev J, Salomon O. Safety of cataract surgery in patients treated with the new oral anticoagulants (NOACs). Graefes Arch Clin Exp Ophthalmol 2019; 257:2671-2676. [PMID: 31641883 DOI: 10.1007/s00417-019-04488-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/09/2019] [Accepted: 09/15/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To evaluate the safety of phacoemulsification of cataract in patients taking new oral anticoagulants (NOACs). METHODS In a prospective case series, consecutive patients on NOACs (dabigatran, rivaroxaban, or apixaban) who were referred for uncomplicated cataract surgery to the eye institute underwent a thorough ophthalmological and hematological evaluation. Rivaroxaban and apixaban anti-factor Xa tests, and diluted thrombin time for dabigatran, were used for monitoring anticoagulation levels in blood. Blood was drawn for these tests just prior to surgery and at a peak level of the drug at about 4 h post-surgery (2 h after the drug was given). All surgeries were videotaped and patients were examined at 1 and 7 days after the operation. The main outcome measures included assessment of intra-operative, postoperative ocular bleeding, and other related complications. RESULTS Thirty-five eyes of 25 unrelated patients ranging in age from 63 to 92 years (mean 77.6 years) underwent phacoemulsification. Intra-operative bleeding was observed in 5 eyes from the conjunctiva or limbus at the main incision site. No intraocular bleeding occurred. No hemorrhagic complications were observed during the 1-week follow-up. According to anti-factor Xa levels prior to surgery and following surgery, 85% of the patients were on therapeutic levels of NOACs. CONCLUSIONS Clear corneal incision phacoemulsification performed under topical anesthesia can be safely performed in simple cases of cataract without discontinuing NOAC treatment.
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Affiliation(s)
- Irina S Barequet
- Goldschleger Eye Institute, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv University, Tel Hashomer, Israel.
| | - Tzukit Zehavi-Dorin
- Goldschleger Eye Institute, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv University, Tel Hashomer, Israel
| | - Nirit Bourla
- Goldschleger Eye Institute, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv University, Tel Hashomer, Israel
| | - Ilia Tamarin
- Institute of Thrombosis & Hemostasis, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv, University, Tel Hashomer, Israel
| | - Joseph Moisseiev
- Goldschleger Eye Institute, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv University, Tel Hashomer, Israel
| | - Ophira Salomon
- Institute of Thrombosis & Hemostasis, Sheba Medical Center, Sackler Faculty of Medicine, Tel - Aviv, University, Tel Hashomer, Israel
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Makuloluwa AK, Tiew S, Briggs M. Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye (Lond) 2019; 33:1044-1059. [PMID: 30850731 DOI: 10.1038/s41433-019-0382-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/25/2018] [Accepted: 01/20/2019] [Indexed: 12/14/2022] Open
Abstract
There is variability in the management of ophthalmic patients on anti-thrombotic agents (antiplatelets and anticoagulants) during the peri-operative period. A survey carried out in a UK teaching hospital on a cohort of ophthalmologists showed majority were comfortable with antiplatelet management but there was variability in managing patients on warfarin and direct oral anticoagulants (DOACs); 40% were unaware of existing guidelines. We aim to review the recommendations in the literature with regards to managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. We reviewed incidences of complications, specifically, the haemorrhagic complications associated. Pubmed search was carried out on relevant keywords from January 2007 to August 2017. All relevant UK guidelines including the Royal College of Ophthalmologists and British Society of Haematology were reviewed. Literature recommendations for routine cataract surgery under topical or sub-Tenon's anaesthesia would be to continue all anti-thrombotic agents. For sharp needle anaesthesia, avoidance of dual antiplatelet therapy was recommended and warfarin could be continued if INR within therapeutic range. Recommendations for surgeries in glaucoma, vitreo-retinal, oculoplastic and lacrimal; and strabismus are presented. No evidence was found for corneal surgery. Haemorrhagic complications are reported in all groups. Limitations of this review include the retrospective nature, lack of randomized control trials and the limited evidence regarding DOACs. It is important for ophthalmologists to be aware of and balance the risk of thromboembolic events and risks of haemorrhagic complications for ophthalmic surgery. A multi-disciplinary approach is recommended for complex cases.
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Affiliation(s)
- A K Makuloluwa
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK.
| | - S Tiew
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
| | - M Briggs
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
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Krauthammer M, Mandelblum J, Spierer O. Corneal Blood Staining after Complicated Cataract Surgery. Case Rep Ophthalmol 2018; 9:421-424. [PMID: 30323760 PMCID: PMC6180266 DOI: 10.1159/000492612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/31/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose To report the case of a patient with corneal blood staining after a complicated cataract surgery. Observations We report on a 68-year-old woman who developed corneal blood staining secondary to hyphema after cataract surgery, despite the fact that intraocular pressure was not increased for a prolonged time. The corneal staining spontaneously cleared from the periphery towards the center. It was fully resolved after 2.5 years of follow-up. Conclusions and Importance In case of hyphema induced by cataract surgery, performance of early anterior chamber washout should be considered to prevent corneal blood staining and poor visual outcome.
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Affiliation(s)
- Mark Krauthammer
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jorje Mandelblum
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oriel Spierer
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Phacoemulsification cataract surgery in patients receiving novel oral anticoagulant medications. Int Ophthalmol 2018; 39:623-630. [PMID: 29435797 DOI: 10.1007/s10792-018-0862-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/03/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION An increasing number of patients are taking novel oral anticoagulant (NOAC) medication, making perioperative management in phacoemulsification surgery an important issue. This study reports the haemorrhagic complications of NOAC in phacoemulsification surgery. DESIGN Retrospective case study over a 4-year period. METHODS Consecutive cases receiving NOAC during the time of phacoemulsification were reviewed. Patients were either advised to continue medications (continued group) or withhold medications before surgery (withheld group). MAIN OUTCOME MEASURES Details including patient demographics, preoperative assessment, postoperative outcome and intraoperative, postoperative and systemic complications were recorded. RESULTS A total of 20,100 cases of phacoemulsification were performed. Of which, 66 cases were found to be on NOAC (0.33%). This included 66 eyes of 53 patients, with 42 continued and 24 withheld medications before surgery. There was no statistically significant difference between the two groups in demographics, cataract risk factors, baseline renal function, clotting profile, type of NOAC, incision size, phacoemulsification energy, preoperative and postoperative visual acuity. There was also no significant difference in intraoperative, postoperative and systemic complications (p = 1.00 and 0.53, Fischer's exact test). None of the patients in the continued group had postoperative complications; two cases in the withheld group receiving retrobulbar anaesthesia had bruising and subconjunctival haemorrhage after resumption of NOAC (p = 0.13, Fischer's exact test). CONCLUSION The present study found no difference in haemorrhagic complications between cases continuing and withholding NOAC during phacoemulsification. Nevertheless, the potential risks and benefits to continue or withhold NOAC perioperatively should be carefully considered via a multidisciplinary approach.
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Continuation of anticoagulant and antiplatelet therapy during phacoemulsification cataract surgery. Curr Opin Ophthalmol 2015; 26:28-33. [PMID: 25390860 DOI: 10.1097/icu.0000000000000117] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Grzybowski A, Prasad S. Anticoagulant therapy is not a risk factor for choroidal haemorrhage. Graefes Arch Clin Exp Ophthalmol 2014; 252:2023. [PMID: 25277171 PMCID: PMC4245488 DOI: 10.1007/s00417-014-2807-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 09/16/2014] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, Poznan City Hospital, ul. Szwajcarska 3, 61-285, Poznań, Poland,
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MAINTENANCE OF ANTICOAGULANT AND ANTIPLATELET AGENTS FOR PATIENTS UNDERGOING PERIBULBAR ANESTHESIA AND VITREORETINAL SURGERY. Retina 2012; 32:1868-73. [DOI: 10.1097/iae.0b013e31825097ae] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1033] [Impact Index Per Article: 86.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Barequet IS, Sachs D, Shenkman B, Priel A, Wasserzug Y, Budnik I, Moisseiev J, Salomon O. Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg 2011; 37:1434-8. [DOI: 10.1016/j.jcrs.2011.02.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 02/19/2011] [Accepted: 02/23/2011] [Indexed: 10/18/2022]
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Epidemiology of the association between anticoagulants and intraocular hemorrhage in patients with neovascular age-related macular degeneration. Retina 2011; 30:1573-8. [PMID: 21060269 DOI: 10.1097/iae.0b013e3181e2266d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the cumulative incidence and annual incidence of intraocular hemorrhage (subretinal hemorrhage or vitreous hemorrhage) in patients with neovascular age-related macular degeneration (AMD) and association with daily antiplatelet or anticoagulant (AP/AC) medication usage (aspirin, clopidogrel, and warfarin), age, gender, hypertension, diabetes mellitus, or bilateral neovascular AMD. METHODS Retrospective cross-sectional study in a tertiary university setting. Data on 195 eyes of 195 patients without previous intraocular hemorrhage examined over 73 months were reviewed. RESULTS Ninety-six of 195 patients (49.2%) were taking daily AP/ACs. Of patients taking daily AP/AC agents, 63.5% had hemorrhage compared with 29.2% of patients not taking (odds ratio = 4.21; 95% confidence interval = 1.42-8.46; P < 0.001). The overall annual incidence of intraocular hemorrhage was 0.14% per year. Among patients taking daily AP/AC, the cumulative incidence (61 of 96, 63.5%) and annual incidence (0.10%) of concurrent intraocular hemorrhage were significantly greater compared with patients not taking them (29 of 99, 29.2% and 0.04%, respectively; P < 0.0001). Fourteen of 18 patients (77%) taking more than 1 daily AP/AC had occurrence of intraocular hemorrhage. Antiplatelet or anticoagulant usage was an independent risk factor for the development of intraocular hemorrhage. The use of any agent resulted in a significantly increased risk of developing intraocular hemorrhage. Additionally, presence of bilateral neovascular AMD was a significant association in those taking daily AP/ACs, whereas age was a significant association in those not taking daily AP/AC agents. CONCLUSION All three daily AP/AC types were significantly associated with an increased risk of the development intraocular hemorrhage in patients with neovascular AMD, whereas gender, hypertension, and diabetes were not. Age was not significantly associated with hemorrhage in patients taking daily AP/AC agents, whereas the presence of bilateral neovascular AMD was significantly associated with hemorrhage. These findings indicate that the AP/AC use may predispose patients with neovascular AMD to intraocular hemorrhage more so than age and duration of disease alone. While the risk that discontinuing these medicines would pose to the patients' health may be too great to justify, ensuring that an appropriate medication dosage is maintained should be a priority within this patient population.
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Saumier N, Lorne E, Dermigny F, Walkzak K, Daelman F, Jezraoui P, Mahjoub Y, Milazzo S, Dupont H. [Safety of "needle" regional anaesthesia for anterior segment surgery under antiplatelet agents and anticoagulants therapies]. ACTA ACUST UNITED AC 2010; 29:878-83. [PMID: 21112731 DOI: 10.1016/j.annfar.2010.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 08/31/2010] [Indexed: 11/19/2022]
Abstract
INTRODUCTION cataracts preferentially affect the elderly. More than 560,000 procedures are performed annually in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet and/or anticoagulants. Haemorrhagic complications resulting from cataract surgery and/or eye regional anaesthesia are rare but can lead to serious damage to eye function. PATIENTS AND METHODS in this study, we compared the management care of two types of antiplatelet and/or anticoagulants successively utilizing the following procedure: first, the cessation of antiplatelet agents and anticoagulants were relayed with rapid elimination agents (constituting our reference "before" cohort [November 2004-May 2005]), then the antiplatelet or anticoagulant management was continued without stint according to recent data from literature (constituting our "after" cohort (April 2007-March 2008)). RESULTS a reference population, consisting of 229 patients, was operated on exclusively with "surgical" sub-Tenon's anaesthesia. A second group, consisting of 178 patients, was operated on using "needle" regional anaesthesia. In both populations, nearly 33% of patients received antiplatelet or anticoagulant treatment. The incidence of subconjonctival haemorrhage occurred more frequently when anticoagulants agents were relayed (33% vs 0%; P<0,05), but there was no significant difference with antiplatelet agents (23% vs 8%; NS). The most common non-bleeding event was Chemosis and related to the type of anaesthetic technique utilized, although not serious it tended to jeopardize surgical comfort (anticoagulants: 35% vs 36% (NS), antiplatelet agents: 38% vs 40%; NS). CONCLUSION the technical changes do not explain fully that occurrence of the HSC, in patients under anticoagulant treatment, decreased in the second period. The achievement of "needle" regional anaesthesia in the anterior segment eye surgery is a safe technique that does not require stopping antiplatelet treatment or anticoagulation.
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Affiliation(s)
- N Saumier
- Pôle d'anesthésie-réanimation, centre hospitalier universitaire d'Amiens, université Jules-Verne-de-Picardie, avenue René-Laennec, 80054 Amiens cedex, France
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Chen CK, Tseng VL, Wu WC, Greenberg PB. Survey of the management of antithrombotic therapy in cataract surgery patients. J Cataract Refract Surg 2010; 36:1239-40. [PMID: 20610107 DOI: 10.1016/j.jcrs.2010.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Indexed: 10/19/2022]
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Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract surgery. J Cataract Refract Surg 2010; 36:1115-9. [DOI: 10.1016/j.jcrs.2010.01.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 12/29/2009] [Accepted: 01/02/2010] [Indexed: 11/23/2022]
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Rumelt S, Treviño A. Delayed Suprachoroidal Hemorrhage after Reinstitution of Warfarin in Combined Procedure. Ophthalmic Surg Lasers Imaging Retina 2010; 41:1-2. [PMID: 20337326 DOI: 10.3928/15428877-20100215-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2009] [Indexed: 11/20/2022]
Abstract
A 79-year-old non-compliant male with pseudoexfoliative glaucoma and cataract in the left eye underwent uneventful combined phacoemulsification, posterior chamber intraocular lens insertion and trabeculectomy with mitomycin C through one port a week after replacement of warfarin with subcutaneous injections of enoxaparin (Clexane; Sanofi-Aventis, Netaniya, Israel). The intraocular pressure (IOP) following surgery was zero. Four days later, warfarin was restarted because of short ventricular tachycardia when the patient developed suprachoroidal hemorrhage and later hyphema and vitreous hemorrhages. The patient underwent drainage of the suprachoroidal hemorrhage. His IOP increased to 10 to 12 mm Hg while the bleb was functioning, but visual acuity remained poor because of chorioretinal retinal scarring from age-related macular degeneration. Premature reinstitution of warfarin may cause delayed hemorrhages if the postoperative IOP is low. Preoperative approval from the internist for a prolonged replacement of warfarin with lesser potent agents, or tightening of the scleral flap and releasing the sutures later in trabeculectomy in combined procedures may be warranted.
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Subretinal hemorrhages associated with age-related macular degeneration in patients receiving anticoagulation or antiplatelet therapy. Am J Ophthalmol 2010; 149:316-321.e1. [PMID: 19939348 DOI: 10.1016/j.ajo.2009.08.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 08/27/2009] [Accepted: 08/28/2009] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the incidence of and risk factors for subretinal hemorrhages in age-related macular degeneration (AMD) patients on anticoagulation or antiplatelet therapy. DESIGN Retrospective, observational case series. METHODS We retrospectively reviewed the medical and photographic records of 71 consecutive patients who sought treatment at our institution with acute subretinal hemorrhages complicating age-related macular degeneration. The size of the subretinal hemorrhage was measured in standardized Macular Photocoagulation Study disc areas. Data on the use of medications and medical indications for anticoagulation and antiplatelet therapy were obtained. RESULTS Overall, patients receiving antithrombotic therapy had a significantly larger subretinal hemorrhage size (mean, 9.71 disc areas) than patients not receiving anticoagulant or antiplatelet therapy (mean, 2.99 disc areas). Subgroup analysis revealed that both antiplatelet (P < .0001) and anticoagulant therapy (P = .003) were associated with a significantly larger bleeding size. Moreover, subgroup analysis among patients with arterial hypertension revealed that individuals receiving antithrombotic therapy had a statistically significantly larger hemorrhage size than hypertensive patients who did not receive anticoagulants or antiplatelet agents (P < .0001). CONCLUSIONS Our results indicate that anticoagulants and antiplatelet agents are strongly associated with the development of large subretinal hemorrhages in AMD patients. Moreover, arterial hypertension is a strong risk factor for large subretinal hemorrhages in AMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in AMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.
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[Perioperative conversion of oral anticoagulants to heparin (bridging) in ophthalmic medicine]. Ophthalmologe 2009; 107:636-40. [PMID: 20024560 DOI: 10.1007/s00347-009-2088-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Since topical anesthesia was introduced in ophthalmic surgery, anticoagulation therapy can often be used in patients with thromboembolic risk. But some surgical procedures with an increased risk for intraoperative bleeding necessitate changing a patient's Coumadin therapy to heparin. To reduce intraoperative bleeding and perioperative thromboembolic complications, ophthalmologists and referring general practitioners should cooperate closely.
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Fabian ID, Sachs D, Moisseiev J, Alhalel A, Grinbaum A, Seligsohn U, Salomon O. Cataract extraction without prophylactic treatment in patients with severe factor XI deficiency. Am J Ophthalmol 2009; 148:920-4.e1. [PMID: 19733832 DOI: 10.1016/j.ajo.2009.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 07/08/2009] [Accepted: 07/15/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the risks of intraoperative and postoperative bleeding associated with cataract extraction without prophylactic treatment in patients with severe factor XI (FXI) deficiency. DESIGN Prospective interventional case series. METHODS SETTING Single institute. STUDY POPULATION Consecutive unrelated patients with severe FXI deficiency who underwent cataract extraction under topical anesthesia, with a clear corneal incision, phacoemulsification, and implantation of a foldable posterior chamber intraocular lens (PCIOL) were enrolled. Patients with associated intraocular conditions that could complicate the surgery were excluded. INTERVENTION Cataract extraction without prophylactic treatment for the FXI deficiency. MAIN OUTCOME MEASURES Assessment of intraoperative and postoperative ocular bleeding and other related complications. RESULTS Seven patients ranging in age from 61 to 95 years (median, 79) underwent phacoemulsification and PCIOL implantation in 11 eyes. Five patients (71%) were homozygotes for type II mutation of the FXI gene (activity level of <1 U/dl), 1 patient was a homozygote for type III mutation (activity level of 11 U/dl), and 1 patient was a compound heterozygote for types II and III (activity level of 3 U/dl). Three of the patients (43%), all type II homozygotes, also had an inhibitor antibody to FXI. All 7 patients were followed for at least 1 week after the operation. The surgery was uneventful in all eyes, and neither major nor minor bleeding events were observed in any of the operated eyes during surgery and follow-up. CONCLUSIONS Cataract extraction by phacoemulsification in uncomplicated eyes can be performed safely without prophylactic treatment in patients with severe FXI deficiency with or without inhibitor antibodies against FXI.
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Batra R, Maino A, Ch'ng SW, Marsh IB. Perioperative management of anticoagulated patients having cataract surgery. J Cataract Refract Surg 2009; 35:1815-20. [DOI: 10.1016/j.jcrs.2009.05.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 05/23/2009] [Accepted: 05/26/2009] [Indexed: 11/24/2022]
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Jamula E, Anderson J, Douketis JD. Safety of continuing warfarin therapy during cataract surgery: A systematic review and meta-analysis. Thromb Res 2009; 124:292-9. [PMID: 19233450 DOI: 10.1016/j.thromres.2009.01.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 12/04/2008] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
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Current World Literature. Curr Opin Cardiol 2009; 24:95-101. [DOI: 10.1097/hco.0b013e32831fb366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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