In patients undergoing ophthalmic surgery, the use of warfarin, direct oral anticoagulants (DOACs), and antiplatelet agents (such as aspirin and clopidogrel) is common. These drugs reduce the risk of systemic thromboembolism, but they may increase the risk of perioperative bleeding.
The main challenge for ophthalmologists is balancing the risk of thrombosis from stopping treatment with the risk of bleeding from continuing treatment. This decision is not made the same way for everyone; it is individualized based on both the patient’s overall thrombotic risk and the bleeding risk of the surgery.
In Japan’s 2009 revised guideline for anticoagulant and antiplatelet therapy in cardiovascular disease, cataract surgery is recommended as a Class IIa procedure both when antiplatelet therapy is continued and when warfarin is continued with PT-INR controlled within the optimal therapeutic range. The optimal PT-INR range in Japanese patients is 2.0–3.0 for those under 70 years old and 1.6–2.6 for those 70 years and older.
Warfarin
Mechanism: Vitamin K antagonist. Reduces the activity of coagulation factors II, VII, IX, and X.
Half-life: About 36–42 hours.
Preoperative interruption: Stop about 5 days before surgery. Check the INR on the day of surgery.
Reversal: Vitamin K ± 4-factor PCC.
DOAC
Examples: Dabigatran, apixaban, rivaroxaban, edoxaban.
Half-life: relatively short, 5–17 hours.
Preoperative discontinuation: 24–48 h if CrCl ≥50, and 48–72 h if CrCl 30–49.
Reversal: dabigatran with idarucizumab; Xa inhibitors with andexanet alfa.
| Risk | Representative procedures |
|---|---|
| Extremely low | Intravitreal injection, YAG laser, selective/argon laser trabeculoplasty, retinal photocoagulation |
| Low | Clear corneal cataract surgery (topical/Sub-Tenon anesthesia), simple pterygium |
| Moderate | Minimally invasive glaucoma surgery (MIGS), strabismus surgery, ectropion/entropion correction, endothelial keratoplasty (DSAEK/DMEK) |
| High | Trabeculectomy, tube shunt, vitrectomy, penetrating keratoplasty, dacryocystorhinostomy, orbital surgery |
In many cases, it is not necessary. Cataract surgery performed with topical anesthesia or a corneal incision has a low bleeding risk, and Japanese guidelines also recommend surgery under continued antiplatelet and anticoagulant therapy as Class IIa.
For cataract surgery with topical anesthesia or sub-Tenon anesthesia using a corneal incision, continuation of antithrombotic therapy is possible in most patients. The CHEST 2022 guidelines also recommend continuing anticoagulants and antiplatelet agents during minor ophthalmic surgery (such as cataract surgery) [1]. In Jamula’s systematic review and meta-analysis, bleeding events increased in cataract surgery under continued warfarin, but most were self-limited and did not threaten vision [3]. The rate of subconjunctival hemorrhage increases, but sight-threatening bleeding complications are rare [6].
Retrobulbar anesthesia carries a rare but serious risk of retrobulbar hemorrhage, so a sub-Tenon’s cannula technique or fully topical anesthesia is recommended.
Trabeculectomy and tube shunt surgery have a risk of anterior chamber hemorrhage and suprachoroidal hemorrhage, and the consequences of bleeding are greater than with cataract surgery. If the thrombotic risk allows a short interruption, consider withholding DOACs and P2Y12 inhibitors. Aspirin is continued in many cases. Minimally invasive glaucoma surgery has a varied bleeding profile and should be individualized according to the device type.
Antithrombotic drugs are usually continued for intravitreal injections and outpatient laser treatment (panretinal photocoagulation, focal photocoagulation). In a retrospective study by Lauermann et al., the use of antiplatelet and anticoagulant drugs was not a significant risk factor for severe intraoperative bleeding in vitreoretinal surgery, and comorbid factors such as diabetes, carotid artery stenosis, younger age, and combined scleral buckle surgery were more strongly associated [4]. A systematic review by Confalonieri et al. also found that vitreoretinal surgery performed while continuing antithrombotic therapy is generally safe, although evidence on DOACs remains limited [7]. For posterior segment surgery with extensive proliferative membrane peeling or long procedures involving scleral buckle, temporary interruption of P2Y12 inhibitors and DOACs may be considered when systemic risk is acceptable, and aspirin should be continued whenever possible.
Superficial corneal surgery and simple pterygium surgery are often performed while antithrombotic drugs are continued. Corneal lesions with neovascularization and full-thickness corneal transplantation require more careful planning.
Surgery involving deep dissection posterior to the orbital septum carries the highest risk of orbital hematoma, which can cause vision loss [5]. According to a review by Kim et al., in superficial anterior eyelid procedures (such as chalazion excision and eyelid skin excision), sight-threatening bleeding is rare even when antithrombotic drugs are continued, whereas the risk increases in surgery posterior to the orbital septum and in orbital surgery [5]. For elective surgery, interruption of P2Y12 inhibitors and DOACs may be considered, but aspirin may be continued after confirmation with cardiology.
Yes. In particular, antiplatelet drugs after coronary stent placement and anticoagulants in patients with mechanical valves must always have the possibility of interruption confirmed with the prescribing physician (e.g., a cardiologist), because inappropriate interruption can lead to fatal complications.
Bridging therapy means temporarily using a short-acting injectable anticoagulant (such as low-molecular-weight heparin) during the period when an oral anticoagulant is stopped.
The BRIDGE trial (NEJM 2015) showed in a randomized controlled trial that routine perioperative bridging was noninferior for preventing arterial thromboembolism in patients with atrial fibrillation taking warfarin, while it nearly tripled the risk of major bleeding[2]. Based on this, the CHEST 2022 guideline also does not recommend routine bridging for many patients with atrial fibrillation[1]. With DOACs, because their effect wears off and restarts quickly, bridging is generally unnecessary[1].
These are used for life-threatening bleeding or emergency surgery, but attention is needed to the risk of thrombotic events after reversal.
Warfarin inhibits the synthesis of vitamin K–dependent clotting factors (II, VII, IX, X). DOACs directly inhibit thrombin (dabigatran) or factor Xa (apixaban, rivaroxaban, edoxaban), providing stable anticoagulant effects without dietary restrictions or frequent monitoring.
Aspirin irreversibly inhibits platelet COX-1 and suppresses thromboxane A2 production. P2Y12 receptor antagonists block ADP-mediated platelet activation. In dual antiplatelet therapy after coronary stent placement, aspirin and a P2Y12 antagonist are usually used together.
DOACs have a short half-life (5–17 hours), and their effect wears off after a 24–72-hour interruption depending on kidney function, so bridging is not needed. Warfarin has a longer half-life (36–42 hours) and requires stopping it about 5 days before and checking the INR.
Evidence for managing antithrombotic drugs in ophthalmic surgery, especially outside cataract surgery, is still limited. The 2022 CHEST guidelines summarized evidence-based timing for stopping and restarting VKA, DOAC, and antiplatelet drugs, and the 2024 AHA/ACC perioperative guidelines presented a stepwise approach that can also be applied to the ophthalmic field.
In the future, more prospective studies and randomized controlled trials by ophthalmic subspecialty are desired. In particular, data are needed on the risk of bleeding in vitrectomy and glaucoma surgery among patients using DOACs.
Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e243. PMID: 35964704. https://pubmed.ncbi.nlm.nih.gov/35964704/
Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833. PMID: 26095867. https://pubmed.ncbi.nlm.nih.gov/26095867/
Jamula E, Anderson J, Douketis JD. Safety of continuing warfarin therapy during cataract surgery: a systematic review and meta-analysis. Thromb Res. 2009;124(3):292-299. PMID: 19233450. https://pubmed.ncbi.nlm.nih.gov/19233450/
Lauermann P, Klingelhöfer A, Mielke D, et al. Risk Factors for Severe Bleeding Complications in Vitreoretinal Surgery and the Role of Antiplatelet or Anticoagulant Agents. Ophthalmol Retina. 2021;5(8):e23-e29. PMID: 33915331. https://pubmed.ncbi.nlm.nih.gov/33915331/
Kim C, Pfeiffer ML, Chang JR, Burnstine MA. Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines. Ophthalmic Plast Reconstr Surg. 2022;38(3):226-233. PMID: 35019878. https://pubmed.ncbi.nlm.nih.gov/35019878/
Idrees S, Sridhar J, Kuriyan AE. Perioperative management of antiplatelet therapy in ophthalmic surgery. Int Ophthalmol Clin. 2020;60(3):17-30. PMID: 32576720. https://pubmed.ncbi.nlm.nih.gov/32576720/
Confalonieri F, Ferraro V, Di Maria A, et al. Antiplatelets and Anticoagulants in Vitreoretinal Surgery: A Systematic Review. Life (Basel). 2023;13(6):1362. PMID: 37374144. https://pubmed.ncbi.nlm.nih.gov/37374144/
