For oculoplastic and lacrimal surgery, procedures that are carried out posterior to the orbital septum and deep orbital surgery are associated with potentially sight-threatening hemorrhagic complications, and lacrimal surgery also is considered a high-risk procedure. Procedures that are performed anterior to the orbital septum are considered low risk.
“Expert groups on oculoplastic surgery recommend stopping anti-thrombotic agents during blepharoplasty, lacrimal surgery and deep orbital surgery as these are considered high risk for sight-threatening haemorrhagic complications,” the investigators noted.
For strabismus surgery, the recommendations are similar to those for glaucoma and vitreoretinal surgeries. For corneal surgery, no evidence was found. Hemorrhagic complications were reported in all groups.
The authors proposed their pathway for managing patients taking antithrombotic drugs. For low-risk procedures (sub-Tenon/topical cataract, corneal, chalazion, eyelid cyst/lesion removal, and strabismus surgeries), antiplatelets can be continued.
For anticoagulants, the INR should be check on the surgical day and warfarin continued if within the therapeutic range; the DOAC dose is stopped two days preoperatively (depending on renal function) and restarted one to two days postoperatively if adequate hemostasis is achieved.
For high-risk procedures (peri/retrobulbar anesthesia, glaucoma, vitreoretinal (pars plana vitrectomy), vitreoretinal procedures [oncology: endoresection, biopsy of intraocular tumors, plaques/markers], oculoplastics [blepharoplasty, post-septal eyelid surgery], and temporal artery biopsy surgeries], antiplatelets are stopped seven days preoperatively but continued in high-risk patients.
Prasugrel, a platelet-aggregation inhibitor [Effent in the United States; Efent in the European Union] is stopped seven days preoperatively, and Ticagrelor, [a platelet-aggregation inhibitor] five days preoperatively. For the anticoagulants (warfarin), the local anticoagulant service should be informed at the time of listing. If low risk (e.g., non-valvular atrial fibrillation), warfarin should be stopped two days preoperatively, the INR is checked on the surgical day, and continued if <2. Re-start on evening of surgery. If high risk, discuss with physician. For the DOACs, the recommended action is the same as for low-risk procedures.