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Gonzalez-Lopez JJ, Arruza Santos ME, Leon Garcia J. Pars plana vitrectomy in patients aged 85 years and older: a single-centre, retrospective cohort study. Int Ophthalmol 2023; 43:4887-4896. [PMID: 37851142 PMCID: PMC10724084 DOI: 10.1007/s10792-023-02891-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To describe the epidemiology, indications and surgical results of pars plana vitrectomy (PPV) in patients over 85 years of age. METHODS A retrospective cohort study was performed including all consecutive patients aged 85 years or older who underwent PPV between September 2018 and March 2022 in a single hospital in Madrid, Spain. Data on diagnosis, comorbidities, surgical indication, surgical details, surgical complications and surgical outcomes were collected from medical records. RESULTS A total of 124 eyes of 119 patients (56 males, 47.1%) underwent PPV. Median age was 87 years (range 85-96). The most common surgical indications were complications of cataract surgery in 34 patients (28.6%), macular epiretinal membrane in 32 (26.9%), and rhegmatogenous retinal detachment (RRD) in 12 (10.1%). Mean preoperative best corrected visual acuity (BCVA) was 13.33 ± 42.34 ETDRS letters and improved to 40.05 ± 41.04 letters at 3 months (p < 0.001). BCVA had improved in 68.82% of patients at 3 months. Patients with chronic kidney disease (CKD; p < 0.001), RRD (p = 0.003), ocular trauma (p = 0.001) and age-related macular degeneration (AMD; p = 0.002) showed worse BCVA at 3 months from surgery. Patients with better preoperative BCVA (p < 0.001), and those who underwent 25G PPV (p = 0.041) showed better visual outcomes. CONCLUSIONS PPV is an effective technique for improving visual acuity in patients aged 85 years and older with vitreoretinal diseases. Visual outcomes were better when patients had a better preoperative visual acuity and underwent 25G PPV. Patients with a previous diagnosis of AMD or CKD, and those undergoing surgery for ocular trauma or RRD had worse visual outcomes.
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Affiliation(s)
- Julio J Gonzalez-Lopez
- Ophthalmology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Km 9, 100, 28034, Madrid, Spain.
- Surgery Department, Universidad de Alcala School of Medicine, Madrid, Spain.
| | - Maria E Arruza Santos
- Ophthalmology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Km 9, 100, 28034, Madrid, Spain
| | - Jorge Leon Garcia
- Ophthalmology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Km 9, 100, 28034, Madrid, Spain
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Confalonieri F, Ferraro V, Di Maria A, Gaeta A, Vallejo-Garcia JL, Vinciguerra P, Lumi X, Petrovski G. Antiplatelets and Anticoagulants in Vitreoretinal Surgery: A Systematic Review. Life (Basel) 2023; 13:1362. [PMID: 37374144 DOI: 10.3390/life13061362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Background: Antiplatelets and anticoagulants have substantially influenced contemporary vitreoretinal surgical practices. The availability of new oral blood thinners has recently spurred a renewed interest in the clinical approach to vitreoretinal surgical conditions since it may be difficult for the surgeon to collect sufficient evidence-based data to decide whether to discontinue or continue such medications. Materials and Methods: We conducted a systematic review on the use of antiplatelets and/or anticoagulants in the perioperative setting in vitreoretinal surgery and their possible complications, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level of evidence, according to the Oxford Centre for Evidence-Based Medicine (OCEM) 2011 guidelines, and the quality of evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, were assessed for all included articles. Results: In total, 2310 articles were initially extracted, out of which 1839 articles were obtained after duplicates were removed and their abstracts were screened. A total of 27 articles were included in the full-text review. Finally, a remaining 22 articles fulfilled the inclusion criteria. Conclusions: Even though there is just a small number of studies with solid results, the advantage of using antiplatelets and/or anticoagulants in vitreoretinal surgery seems to outweigh the disadvantages, which are mainly related to postoperative hemorrhagic complications.
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Affiliation(s)
- Filippo Confalonieri
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway
| | - Vanessa Ferraro
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandra Di Maria
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Gaeta
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Viale Benedetto XV, 6, 16132 Genova, Italy
| | - Josè Luis Vallejo-Garcia
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Paolo Vinciguerra
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Xhevat Lumi
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Eye Hospital, University Medical Centre Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
| | - Goran Petrovski
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway
- Department of Ophthalmology, University of Split School of Medicine and University Hospital Centre, 21000 Split, Croatia
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Kishore K, Hariprasad SM, Mungee S. Perioperative Antiplatelet Agents and Anticoagulants in Vitreoretinal Surgery. Ophthalmic Surg Lasers Imaging Retina 2022; 53:71-78. [PMID: 35148217 DOI: 10.3928/23258160-20220128-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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4
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Guise PA, Wang K. Haemorrhagic complications following cataract and vitreoretinal surgery with sub-Tenon's block in patients receiving non-vitamin K oral anticoagulant agents: A prospective audit. Anaesth Intensive Care 2022; 50:289-294. [PMID: 35078342 DOI: 10.1177/0310057x211057136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is a lack of data to support either continuation or interruption of non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery. A prospective audit was undertaken of 291 patients undergoing cataract surgery or vitreoretinal surgery, predominantly under sub-Tenon's block, while continuing these agents. The median time from last non-vitamin K oral anticoagulant dose to the insertion of sub-Tenon's block was five hours. No patient required emergency reversal of anticoagulation. There were no sight-threatening complications in the immediate perioperative period, although two vitreoretinal patients (3.8%) had a moderate haemorrhagic complication on day five, and two cataract patients (0.8%) had a minor haemorrhagic complication on days one and 14 postoperatively. Despite continuing their non-vitamin K oral anticoagulants, three (1%) cataract patients had a moderate thromboembolic complication within the 30-day postoperative period. The risk of haemorrhagic complications associated with continuation of anticoagulation with non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery is low, and this audit supports the continuation of non-vitamin K oral anticoagulants for our patients having cataract and vitreoretinal surgery.
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Affiliation(s)
- Philip A Guise
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Kailun Wang
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Clinical characteristics and mortality rates for suprachoroidal hemorrhage: seven-year experience at a tertiary eye center. Graefes Arch Clin Exp Ophthalmol 2021; 260:949-956. [PMID: 34523070 DOI: 10.1007/s00417-021-05290-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To investigate comorbidities and medications associated with acute (ASCH) and delayed (DSCH) suprachoroidal hemorrhage (SCH), and to explore visual outcomes and mortality following SCH. METHODS Retrospective review of SCH cases diagnosed at a tertiary center between 2013 and 2019. Demographics, history, surgery type, visual acuity, intraocular pressure (IOP), and mortality data were reviewed. RESULTS Fifty eyes of 50 patients experienced SCH related to surgery: 15 (30%) ASCH and 35 (70%) DSCH. Glaucoma surgery was the most common preceding surgery, and SCH was more likely to be delayed in glaucoma surgery relative to other surgeries (p = 0.001). The proportions of patients on anticoagulant, antiplatelet, or NSAID medications were 30% (n = 15), 52% (n = 26), and 12% (n = 6), respectively. The mean preoperative IOP was 25.0 ± 10.2 mmHg. The mean final best corrected visual acuity did not significantly differ between DSCH and ASCH (logMAR 1.92 vs. 2.36; p = 0.39). After controlling for pre-drainage visual acuity, final visual acuity was not statistically significantly different between eyes that were drained versus those that were not drained (p = 0.06). Of all 50 patients, the mortality rate was 12% with a mean time to mortality after SCH of 754 ± 564 days for those who died. CONCLUSION DSCH was more common than ASCH, with glaucoma surgery being the most common procedure to result in SCH. Visual outcomes and mortality rate were comparable between ASCH and DSCH. Further research is needed regarding the role of surgical drainage on improving visual outcomes in eyes with SCH.
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Starr MR, Ammar MJ, Patel LG, Boucher N, Yonekawa Y, Garg SJ, Hsu J, Ho AC, Regillo CD, Chiang A. Comparative Incidence of Postoperative Hemorrhage in Vitreoretinal Surgery in Patients on Anti-Coagulants. Ophthalmic Surg Lasers Imaging Retina 2021; 52:374-379. [PMID: 34309424 DOI: 10.3928/23258160-20210628-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Data regarding hemorrhagic complications of direct oral anticoagulants (DOACs) and vitreoretinal surgery are limited. PATIENTS AND METHODS Multicenter analysis of longitudinal, aggregated electronic health records of patients undergoing pars plana vitrectomy (PPV) with no prior history of ocular hemorrhage. Retrospective analysis of patients undergoing PPV between January 1, 2013, and December 31, 2019. The main outcomes were development of postoperative hemorrhagic complications within 1 month following vitreoretinal surgery. RESULTS A total of 58,131 eyes underwent PPV, with 2,956 (5.1%) on anticoagulant medication prior to surgery. Eight hundred twenty-eight eyes (1.4%) developed a postoperative hemorrhage. Of eyes with anticoagulation use, 50 of 2,956 (1.29%) developed a hemorrhage, whereas 778 of 55,175 (1.41%) of the eyes with no prior anticoagulation use developed a postoperative hemorrhage (P = .2107). CONCLUSION Use of DOACs prior to vitreoretinal surgery does not appear to be associated with increased rates of postoperative intraocular hemorrhage. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:374-379.].
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Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery. ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA 2021; 96:422-429. [PMID: 34340780 DOI: 10.1016/j.oftale.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. OBJECTIVE To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. MATERIAL AND METHODS A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. RESULTS Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. CONCLUSIONS There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.
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Herranz-Heras JC, Alcalde-Blanco L, Cañas-Zamarra I, Mencía-Gutiérrez E, Ferro-Osuna M, Pérez-Trigo S. Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery. ACTA ACUST UNITED AC 2020. [PMID: 33371998 DOI: 10.1016/j.oftal.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. OBJECTIVE To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. MATERIAL AND METHODS A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. RESULTS Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. CONCLUSIONS There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.
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Affiliation(s)
- J C Herranz-Heras
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España.
| | - L Alcalde-Blanco
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - I Cañas-Zamarra
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - E Mencía-Gutiérrez
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - M Ferro-Osuna
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - S Pérez-Trigo
- Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, España
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Andonegui J, Zubicoa A. Anticoagulants And Vitreoretinal Surgery. ACTA ACUST UNITED AC 2020; 95:365-366. [PMID: 32493636 DOI: 10.1016/j.oftal.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- J Andonegui
- Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España; Red Temática de Investigación Cooperativa en Oftalmología RD 12/0034 «Oftalred».
| | - A Zubicoa
- Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona, España
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10
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Risk of perioperative bleeding complications in rhegmatogenous retinal detachment surgery: a retrospective single-center study. Graefes Arch Clin Exp Ophthalmol 2020; 258:961-969. [DOI: 10.1007/s00417-019-04554-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
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Chen AF, He X, Nirwan RS, Sridhar J, Kuriyan AE. Perioperative Management of Anticoagulants in Ocular Surgeries. Int Ophthalmol Clin 2020; 60:3-15. [PMID: 32576719 PMCID: PMC7334869 DOI: 10.1097/iio.0000000000000316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.
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Affiliation(s)
- Alexander F. Chen
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Xu He
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Rajinder S. Nirwan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
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12
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Abstract
Many patients undergoing ophthalmic surgery are elderly with comorbidities requiring antiplatelet therapy to prevent thromboembolic or atherothrombotic events. The use of antiplatelet therapy has expanded over the years, predisposing these patients to hemorrhagic complications perioperatively. The risk of hemorrhagic complications must be weighed against the risk of thromboembolic events with cessation of antiplatelet therapy. The decision to continue or interrupt antiplatelet therapy in the setting of ophthalmic surgery is based upon various factors, including the type of surgery and each patient’s comorbidities. This review examines the risks of thrombotic complications versus hemorrhagic complications in different types of ophthalmic surgeries with the use of antiplatelet medications and provides evidence-based recommendations regarding perioperative management of antiplatelet therapy
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Affiliation(s)
- Sana Idrees
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Jayanth Sridhar
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
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Andonegui J, Capdevila F, Zubicoa A, Ibáñez B. Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events. Trials 2019; 20:677. [PMID: 31801597 PMCID: PMC6894279 DOI: 10.1186/s13063-019-3805-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra- and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy (PPV) under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients with an interruption in this therapy before surgery. METHODS Ninety-six patients will be randomly assigned to either the control group, in whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group in whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated. DISCUSSION This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy. TRIAL REGISTRATION Clinical Trials Register EudraCT, 2018-000753-45. Registered on 11 November 2018.
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Affiliation(s)
- Jose Andonegui
- Department of Ophthalmology, Complejo Hospitalario de Navarra, 31007, Pamplona, Spain. .,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.
| | - Ferran Capdevila
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Pamplona, Spain
| | - Alicia Zubicoa
- Department of Ophthalmology, Complejo Hospitalario de Navarra, 31007, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Berta Ibáñez
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Pamplona, Spain.,Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Pamplona, Spain
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14
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Feltgen N, Mele B, Dietlein T, Erb C, Eckstein A, Hager A, Heiligenhaus A, Helbig H, Hoerauf H, Hoffmann E, Pauleikhoff D, Schittkowski M, Seitz B, Sucker C, Suffo S, Schaudig U, Tost F, Thurau S, Walter P, Koscielny J. [Management of anticoagulants in ophthalmic surgery-a survey among ophthalmic surgeons in Germany]. Ophthalmologe 2019; 115:585-591. [PMID: 29770858 DOI: 10.1007/s00347-018-0732-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION As our population ages and comorbidities rise, ophthalmic surgeons are increasingly faced with patients on anticoagulant therapy or with clotting disorders. The ophthalmic surgeon has to weigh the perioperative risk of haemorrhage when anticoagulation continues against the risk of thromboembolism caused by discontinuation or changing the patient's medication (bridging, switching, cessation). There are currently no guidelines or recommendations. METHODS A survey was sent to the DOG (German Ophthalmologic Society) divisions and associated surgical organizations to determine the status quo. A questionnaire was sent out and filled out by the different groups of specialists. RESULTS All four divisions of the DOG and four associated organizations returned completed questionnaires. Surgical interventions were listed that are carried out during anticoagulant therapy without exceptions, as well as interventions that were classified to require medical adjustment. Although the assessments varied, general consensus was achieved regarding interventions not requiring adjustments due to anticoagulants (i. e., intravitreal injection, cataract surgery, laser and corneal operations, simple muscle surgery), and those interventions requiring adjustments in medications (glaucoma operations, complex retina surgery, eye socket surgery, complex surgery of the lid). CONCLUSION Main result of this survey was the specification of serious bleeding complications which are permanent vision loss and re-operation. They could serve as endpoint parameters for essential future investigations. Nevertheless, this survey makes clear that the decision about an adjustment of anticoagulant medication in ophthalmic surgery is currently made individually and not based on established standards.
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Affiliation(s)
- N Feltgen
- Klinik für Augenheilkunde, Universitätsklinikum Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland.
| | - B Mele
- DOG Geschäftsstelle, Platenstr. 1, 80336, München, Deutschland
| | - T Dietlein
- Klinik für Augenheilkunde, Universitätsklinikum Köln, Köln, Deutschland
| | - C Erb
- Augenklinik am Wittenbergplatz, Berlin, Deutschland
| | - A Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Essen, Deutschland
| | - A Hager
- Augenarztpraxis am Elsterplatz, Berlin, Deutschland
| | | | - H Helbig
- Klinik für Augenheilkunde, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - H Hoerauf
- Klinik für Augenheilkunde, Universitätsklinikum Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | - E Hoffmann
- Klinik für Augenheilkunde, Universitätsklinikum Mainz, Mainz, Deutschland
| | - D Pauleikhoff
- St. Franziskus-Hospital Münster, Münster, Deutschland
| | - M Schittkowski
- Klinik für Augenheilkunde, Universitätsklinikum Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | - B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Homburg/Saar, Deutschland
| | - C Sucker
- Gerinnungszentrum Berlin Dr. Sucker, Berlin, Deutschland
| | - S Suffo
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Homburg/Saar, Deutschland
| | - U Schaudig
- Augenklinik, Asklepios Klinik Barmbek, Hamburg, Deutschland
| | - F Tost
- Klinik für Augenheilkunde, Universitätsklinikum Greifswald, Greifswald, Deutschland
| | - S Thurau
- Klinik für Augenheilkunde, Universitätsklinikum München, LMU, München, Deutschland
| | - P Walter
- Klinik für Augenheilkunde, Universitätsklinikum Aachen, Aachen, Deutschland
| | - J Koscielny
- Gerinnungsambulanz und Hämophiliezentrum an der Charité, Berlin, Deutschland
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Rezkallah A, Didier C, Denis P, Mathis T, Kodjikian L. Sub-Tenon anesthesia, maintained oral anticoagulant and antiplatelet therapies and vitreoretinal surgery: About 68 cases. J Fr Ophtalmol 2019; 42:e239-e240. [PMID: 31101363 DOI: 10.1016/j.jfo.2018.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Amina Rezkallah
- Department of Ophthalmology, University of Lyon, Croix-Rousse University Hospital, Hospices Civils de Lyon, 03, Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France; UMR-CNRS 5510 Matéis, University of Medicine Lyon 1, 69004 Lyon, France
| | - Claudine Didier
- Department of Anesthesiology, University of Lyon, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69004 Lyon, France; UMR-CNRS 5510 Matéis, University of Medicine Lyon 1, 69004 Lyon, France
| | - Philippe Denis
- Department of Ophthalmology, University of Lyon, Croix-Rousse University Hospital, Hospices Civils de Lyon, 03, Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France; UMR-CNRS 5510 Matéis, University of Medicine Lyon 1, 69004 Lyon, France
| | - Thibaud Mathis
- Department of Ophthalmology, University of Lyon, Croix-Rousse University Hospital, Hospices Civils de Lyon, 03, Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France; UMR-CNRS 5510 Matéis, University of Medicine Lyon 1, 69004 Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, University of Lyon, Croix-Rousse University Hospital, Hospices Civils de Lyon, 03, Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France; UMR-CNRS 5510 Matéis, University of Medicine Lyon 1, 69004 Lyon, France.
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16
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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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Arepalli S, Sears JE, Srivastava SK, Deasy R, Singh RP, Ehlers JP, Kaiser PK, Martin D, Sharma S, Yuan A, Schachat AP, Rachitskaya AV. Pre–Retinal Surgery Identification of Novel Anticoagulation and Antiplatelet Agents. ACTA ACUST UNITED AC 2018; 2:254-255. [DOI: 10.1016/j.oret.2017.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/16/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022]
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18
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Uyhazi KE, Miano T, Pan W, VanderBeek BL. Association of Novel Oral Antithrombotics With the Risk of Intraocular Bleeding. JAMA Ophthalmol 2018; 136:122-130. [PMID: 29242919 DOI: 10.1001/jamaophthalmol.2017.5677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Importance Novel oral anticoagulation and antiplatelet therapies have become a mainstay of treatment for thromboembolic disease. However, the safety profile of these medications has not been completely characterized. Objective To determine the risk of developing intraocular hemorrhages with novel oral antithrombotic therapy compared with that of traditional antithrombotic agents. Design, Setting, and Participants In this retrospective cohort study, a large national insurance claims database was used to generate 2 parallel analyses. All patients with incident use of dabigatran etexilate or rivaroxaban between January 1, 2010, and September 30, 2015, were compared with patients with incident use of warfarin sodium. Similarly, patients with new use of prasugrel hydrochloride were compared with those with new use of clopidogrel bisulfate. Both analyses required the patient to be in the insurance plan for at least 24 months prior to initiation of therapy and excluded patients with any previous diagnosis of intraocular hemorrhages or any prescription for the comparator medications. Furthermore, the antiplatelet analysis required a diagnosis of acute coronary syndrome or a myocardial infarction within 60 days of initiation of pharmacologic therapy. The anticoagulant analysis excluded patients with end-stage renal disease, renal transplants, and those with heart valve disease. Main Outcomes and Measures Incident intraocular hemorrhages at 90 and 365 days. Multivariate Cox proportional hazards regression models were used to compare the hazard ratio (HR) of developing an intraocular hemorrhage in individuals taking novel agents compared with those taking traditional medications. Results A total of 146 137 patients taking warfarin (76 714 women and 69 423 men; mean [SD] age, 69.8 [11.8] years) were compared with 64 291 patients taking dabigatran or rivaroxaban (31 576 women and 32 715 men; mean [SD] age, 67.6 [11.7] years). Cox proportional hazards regression revealed a decreased hazard for developing an intraocular hemorrhage with dabigatran or rivaroxaban at 365 days (HR, 0.75; 95% CI, 0.58-0.97; P = .03), but not at 90 days (HR, 0.73; 95% CI, 0.22-2.63; P = .13). A total of 103 796 patients taking clopidogrel (37 578 women and 66 218 men; mean [SD] age, 68.0 [11.3] years) were compared with 8386 patients taking prasugrel (1988 women and 6380 men; mean [SD] age, 61.0 [9.6] years) and no increased hazard for developing an intraocular hemorrhage with prasugrel was seen at 90 days (HR, 0.75; 95% CI, 0.29-1.92; P = .55) or 365 days (HR, 1.19; 95% CI, 0.69-2.04; P = .53). Conclusions and Relevance These results suggest a decreased risk of intraocular hemorrhage associated with novel direct thrombin inhibitors and direct factor Xa inhibitors, but no difference for P2Y12 inhibitors compared with traditional vitamin K anticoagulation and antiplatelet therapy, respectively.
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Affiliation(s)
- Katherine E Uyhazi
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Todd Miano
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Wei Pan
- Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Brian L VanderBeek
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia
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19
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Antiplatelet and anticoagulant agents in vitreoretinal surgery: a prospective multicenter study involving 804 patients. Graefes Arch Clin Exp Ophthalmol 2018; 256:461-467. [DOI: 10.1007/s00417-017-3897-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/08/2017] [Accepted: 12/29/2017] [Indexed: 01/07/2023] Open
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20
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Patel R, Charles S, Jalil A. Antiplatelets and anticoagulants in vitreoretinal surgery, with a special emphasis on novel anticoagulants: a national survey and review. Graefes Arch Clin Exp Ophthalmol 2017; 255:1275-1285. [DOI: 10.1007/s00417-017-3664-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/17/2017] [Accepted: 03/27/2017] [Indexed: 01/28/2023] Open
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21
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Mantopoulos D, Vavvas DG, Fine HF. Perioperative Risks of Antiplatelet and Anticoagulant Drugs in Vitreoretinal Procedures. Ophthalmic Surg Lasers Imaging Retina 2017; 48:4-8. [DOI: 10.3928/23258160-20161219-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Al-Motowa S, Ahmad N, Khandekar R, Zahoor A. Comparison of Olive Tipped and Conventional Steven's Cannula for Sub-Tenon Ophthalmic Anesthesia. Middle East Afr J Ophthalmol 2016; 23:307-310. [PMID: 27994394 PMCID: PMC5141624 DOI: 10.4103/0974-9233.194080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
PURPOSE: To compare the efficacy of the olive tipped (OT) cannula to the conventional Steven's cannula for sub-Tenon block (STB) before cataract surgery. METHODS: This prospective, randomized, double-masked compared STB delivered in cataract surgery patients with an OT cannula or a conventional Steven's cannula (ST). Outcome variables included the akinesia score and lid movement scores at 5 and 10 min. The patient perception of pain during delivery of the STB and surgery were also compared between groups. Surgeon satisfaction with anesthesia was compared between groups. P <0.05 was statistically significant. RESULTS: There were sixty patients in each group. The age between groups was not statistically different (P = 0.4). The body mass index was higher in the ST group compared to the OT group (P < 0.001). The akinesia score at 5 and 10 min did not differ between groups (P = 0.07 and P = 0.6, respectively). The patient perception of pain during STB and surgery were similar between groups (P = 0.1 and P = 0.06, respectively). There were six patients with mild chemosis and redness in the OT group and 15 patients in the ST group. CONCLUSION: An OT cannula is equally effective as the conventional Steven's cannula for delivering STB anesthesia before cataract surgery.
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Affiliation(s)
- Saeed Al-Motowa
- Department of Outreach and Eligibility, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Nauman Ahmad
- Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Rajiv Khandekar
- Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Abdul Zahoor
- Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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23
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Rajavi Z, Safi S, Javadi MA, Azarmina M, Moradian S, Entezari M, Nourinia R, Ahmadieh H, Shirvani A, Shahraz S, Ramezani A, Dehghan MH, Shahsavari M, Soheilian M, Nikkhah H, Ziaei H, Behboudi H, Farrahi F, Falavarjani KG, Parvaresh MM, Fesharaki H, Abrishami M, Shoeibi N, Rahimi M, Javadzadeh A, Karkhaneh R, Riazi-Esfahani M, Manaviat MR, Maleki A, Kheiri B, Golbafian F. Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population. J Ophthalmic Vis Res 2016; 11:394-414. [PMID: 27994809 PMCID: PMC5139552 DOI: 10.4103/2008-322x.194131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/24/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population. METHODS Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9. RESULTS Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence. CONCLUSION This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.
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Affiliation(s)
- Zhale Rajavi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sare Safi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Azarmina
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Moradian
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Entezari
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Standardization and CPG Development Office, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Alireza Ramezani
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Dehghan
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Shahsavari
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Soheilian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homayoun Nikkhah
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Ziaei
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Behboudi
- Department of Ophthalmology, Gilan University of Medical Sciences, Rasht, Iran
| | - Fereydoun Farrahi
- Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Mohammad Mehdi Parvaresh
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Fesharaki
- Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Abrishami
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasser Shoeibi
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mansour Rahimi
- Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Javadzadeh
- Department of Ophthalmology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Karkhaneh
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Riazi-Esfahani
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Maleki
- Department of Ophthalmology, Al Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Bahareh Kheiri
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
In ophthalmology many patients undergo surgical treatment who need to take anticoagulant medication due to cardiovascular diseases. The proper handling of these drugs requires both correct assessment of the risk of thromboembolism as well as the rating of the risk of surgery-related hemorrhages. While there are established recommendations for estimation of the risk of thromboembolism based on a large body of prospective randomized trials, data regarding the evaluation of the related complications secondary to ophthalmic surgery are limited. In comparison to other surgical procedures, most interventions in ophthalmic surgery tend to have a relatively low risk of bleeding; therefore, in general there is no need to convert or discontinue anticoagulant drugs in patients undergoing opthalmic surgery. The sparse data available justifying the abrupt termination of anticoagulation are contrary to the approach currently widely distributed in clinical practice. This overview covers the relevant knowledge of the perioperative use of anticoagulant drugs. In addition, the data on the risk of hemorrhage in ophthalmological procedures are presented and discussed.
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25
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HEMORRHAGIC RISK OF VITREORETINAL SURGERY IN PATIENTS MAINTAINED ON NOVEL ORAL ANTICOAGULANT THERAPY. Retina 2016; 36:299-304. [DOI: 10.1097/iae.0000000000000783] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Takaschima A, Marchioro P, Sakae TM, Porporatti AL, Mezzomo LA, De Luca Canto G. Risk of Hemorrhage during Needle-Based Ophthalmic Regional Anesthesia in Patients Taking Antithrombotics: A Systematic Review. PLoS One 2016; 11:e0147227. [PMID: 26800356 PMCID: PMC4723334 DOI: 10.1371/journal.pone.0147227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/30/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients undergoing ophthalmic surgery are usually elderly and, due to systemic disease, may be on long-term therapy, such as antithrombotic agents. Rates of hemorrhagic complications associated with invasive procedures may be increased by the use of anticoagulants and antiplatelet agents. OBJECTIVE To compare the incidence of hemorrhagic complications in patients undergoing needle-based ophthalmic regional anesthesia between patients on antithrombotic therapy and those not on such therapy. METHODS A systematic review was conducted by two independent reviewers based on searches of Cochrane, LILACS, PubMed, Scopus, Web of Science, and the "gray" literature (Google Scholar). The end search date was May 8, 2015, across all databases. RESULTS Five studies met the eligibility criteria. In three studies, individual risk of bias was low, and in two of them, moderate. In all studies, no differences regarding mild to moderate incidence of hemorrhagic complications were found between patients using antithrombotics (aspirin, clopidogrel, and warfarin) and those not using them. Rates of severe hemorrhagic complication were very low (0.04%) in both groups, supporting the safety of needle blocks, even in patients using antithrombotics. High heterogeneity across studies prevented meta-analysis. Limitations to these results include low statistical power in three experimental studies and a large 95% confidence interval in the two retrospective cohorts. CONCLUSION In this review, none of the selected studies showed significant bleeding related to needle-based ophthalmic regional anesthesia in association with the use of aspirin, clopidogrel, or vitamin K inhibitors. Since the available data is not powerful enough to provide a reliable evaluation of the true effect of antithrombotics in this setting, new studies to address these limitations are necessary.
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Affiliation(s)
- Augusto Takaschima
- Florianópolis Hospital, Florianópolis, Brazil
- Sianest—Anesthesiology Service, Florianópolis, Brazil
- Brazilian Centre for Evidence-based Research, Health Sciences Centre, Federal University of Santa Catarina, Florianópolis, Brazil
- * E-mail:
| | | | - Thiago M. Sakae
- Unisul—Universidade do Sul de Santa Catarina, Tubarão, Brazil
| | - André L. Porporatti
- Brazilian Centre for Evidence-based Research, Health Sciences Centre, Federal University of Santa Catarina, Florianópolis, Brazil
- University of São Paulo, Bauru, Brazil
| | | | - Graziela De Luca Canto
- Unisul—Universidade do Sul de Santa Catarina, Tubarão, Brazil
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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27
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Abstract
In the past decade ophthalmic anesthesia has witnessed a major transformation. The sun has set on the landscape of ophthalmic procedures performed under general anesthesia at in-hospital settings. In its place a new dawn has ushered in the panorama of eye surgeries conducted under regional and topical anesthesia at specialty eye care centers. The impact of the burgeoning geriatric population is that an increasing number of elderly patients will present for eye surgery. In order to accommodate increased patient volumes and simultaneously satisfy administrative initiatives directed at economic frugality, administrators will seek assistance from anesthesia providers in adopting measures that enhance operating room efficiency. The performance of eye blocks in a holding suite meets many of these objectives. Unfortunately, most practicing anesthesiologists resist performing ophthalmic regional blocks because they lack formal training. In future, anesthesiologists will need to block eyes and manage common medical conditions because economic pressures will eliminate routine preoperative testing. This review addresses a variety of topical issues in ophthalmic anesthesia with special emphasis on cannula and needle-based blocks and the new-generation antithrombotic agents. In a constantly evolving arena, the sub-Tenon's block has gained popularity while the deep angulated intraconal (retrobulbar) block has been largely superseded by the shallower extraconal (peribulbar) approach. Improvements in surgical technique have also impacted anesthetic practice. For example, phacoemulsification techniques facilitate the conduct of cataract surgery under topical anesthesia, and suture-free vitrectomy ports may cause venous air embolism during air/fluid exchange. Hyaluronidase is a useful adjuvant because it promotes local anesthetic diffusion and hastens block onset time but it is allergenic. Ultrasound-guided eye blocks afford real-time visualization of needle position and local anesthetic spread. An advantage of sonic guidance is that it may eliminate the hazard of globe perforation by identifying abnormal anatomy, such as staphyloma.
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Affiliation(s)
- Howard D Palte
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL, USA
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28
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Brillat E, Rouberol F, Palombi K, Quesada JL, Bernheim D, Albaladejo P, Aptel F, Romanet JP, Chiquet C. A case–control study to assess aspirin as a risk factor of bleeding in rhegmatogenous retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol 2015; 253:1899-905. [DOI: 10.1007/s00417-014-2900-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/10/2014] [Accepted: 12/15/2014] [Indexed: 11/30/2022] Open
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29
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Gallice M, Rouberol F, Albaladejo P, Brillat Zaratzian E, Palombi K, Aptel F, Romanet JP, Chiquet C. [Managing antithrombotic therapy in vitreoretinal surgery]. J Fr Ophtalmol 2015; 38:61-73. [PMID: 25577431 DOI: 10.1016/j.jfo.2014.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/21/2014] [Accepted: 07/21/2014] [Indexed: 11/18/2022]
Abstract
Given the growing number of patients on antithrombotic therapy we are increasingly confronted with the management of this therapy before, during and after vitreoretinal surgery. In the absence of a consensus, the decision to withdraw antithrombotic therapy is based on the cardiovascular thromboembolism risk versus the theoretical risk of bleeding if the antithrombotic treatment is continued. As suggested by the literature, antiplatelet therapy (acetylsalicylic acid or clopidogrel) may be safely continued for vitreoretinal surgery, including retinal detachment repair. However, the risk/benefit ratio for patients being treated with two antiplatelet therapies is unknown. It appears that an International Normalized Ratio (INR) less than 3 for patients treated with anticoagulant therapy does not increase the perioperative risk of ocular bleeding. This risk has not been evaluated in patients treated by new antithrombotic therapies (prasugrel, ticagrelor as antiplatelet medication, or dabigatran, rivaroxaban, apixaban as anticoagulant therapy), and there is a need to study it further.
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Affiliation(s)
- M Gallice
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France; Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France
| | - F Rouberol
- Centre ophtalmologique Kleber, 50, cours Franklin-Roosevelt, 69006 Lyon, France
| | - P Albaladejo
- Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France; Département d'anesthésie-réanimation, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France
| | - E Brillat Zaratzian
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France
| | - K Palombi
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France; Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France
| | - F Aptel
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France; Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France
| | - J-P Romanet
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France; Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France
| | - C Chiquet
- Clinique universitaire d'ophtalmologie, CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France; Université Joseph-Fourier, 621, avenue Centrale, 38041 Saint-Martin-d'Hères, France.
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Kong KL, Khan J. Ophthalmic patients on antithrombotic drugs: a review and guide to perioperative management. Br J Ophthalmol 2014; 99:1025-30. [DOI: 10.1136/bjophthalmol-2014-306036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/09/2014] [Indexed: 12/14/2022]
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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Calenda E, Genevois O, Cardon A, Muraine M. Peribulbar anesthesia in 750 patients treated with oral anticoagulants. Int J Ophthalmol 2014; 7:110-3. [PMID: 24634874 DOI: 10.3980/j.issn.2222-3959.2014.01.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/25/2013] [Indexed: 11/02/2022] Open
Abstract
AIM To check the safety of continuation of oral anticoagulants in ophthalmic procedures requiring a peribulbar anesthesia. METHOD A prospective case control study included 750 patients with oral anticoagulants in group A and 750 patients who had never been treated with oral anticoagulant in group B. Hemorrhages were graded as follows: 1) spot ecchymosis of eyelid and or subconjunctival hemorrhage; 2) eyelid ecchymosis involving half of the lid surface area; 3) eyelid ecchymosis all around the eye, no increase in intraocular pressure; 4) retrobulbar hemorrhage with increased intraocular pressure. RESULTS In group A, grade 1 was observed in 13 patients (1.74%) and grade 2 in 2 patients (0.26%). In group B, grade 1 was observed in 12 patients (1.6%) and grade 2 was absent. No 3 or 4 hemorrhage grade was encountered in both groups. There was not significant difference in grade 1 hemorrhage between both groups (P=0.21). CONCLUSION Oral anticoagulants were not associated with a significant increase in potentially sight-threatening local anesthetic complications.
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Affiliation(s)
- Emile Calenda
- Department of Anesthesia, Rouen University Hospital, 1 rue de Germont, Rouen cedex 76031, France
| | - Olivier Genevois
- Department of Ophthalmology, Rouen University Hospital, 1 rue de Germont, Rouen cedex 76031, France
| | - Annie Cardon
- Department of Anesthesia, Rouen University Hospital, 1 rue de Germont, Rouen cedex 76031, France
| | - Marc Muraine
- Department of Ophthalmology, Rouen University Hospital, 1 rue de Germont, Rouen cedex 76031, France
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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34
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Leung RM, Chandra RK, Kern RC, Conley DB, Tan BK. Primary care and upfront computed tomography scanning in the diagnosis of chronic rhinosinusitis: A cost‐based decision analysis. Laryngoscope 2013; 124:12-8. [DOI: 10.1002/lary.24100] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/15/2013] [Accepted: 01/31/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Randy M. Leung
- Department of Otolaryngology–Head and Neck SurgeryUniversity of TorontoToronto Ontario Canada
| | - Rakesh K. Chandra
- Department of Otolaryngology–Head and Neck SurgeryNorthwestern University Feinberg School of MedicineChicago IL
| | - Robert C. Kern
- Department of Otolaryngology–Head and Neck SurgeryNorthwestern University Feinberg School of MedicineChicago IL
| | - David B. Conley
- Department of Otolaryngology–Head and Neck SurgeryNorthwestern University Feinberg School of MedicineChicago IL
| | - Bruce K. Tan
- Department of Otolaryngology–Head and Neck SurgeryNorthwestern University Feinberg School of MedicineChicago IL
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Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
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Finkel JB, Marhefka GD, Weitz HH. Dual antiplatelet therapy with aspirin and clopidogrel: what is the risk in noncardiac surgery? A narrative review. Hosp Pract (1995) 2013; 41:79-88. [PMID: 23466970 DOI: 10.3810/hp.2013.02.1013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Clopidogrel is one of the most commonly prescribed medications and is currently recommended along with aspirin as treatment to be used for 1 year in all patients without contraindications following an acute coronary syndrome. Patients who are committed to clopidogrel therapy due to recent coronary artery stent implantation may require noncardiac surgery during this recommended period of dual antiplatelet therapy (DAPT). Due to differing rates of endothelialization, patients who undergo bare-metal stent implantation generally require ≥ 1 month of uninterrupted DAPT, and those who undergo drug-eluting stent implantation require ≥ 12 months. Many surgeons ask their patients to stop taking clopidogrel in advance of their procedure to decrease perioperative bleeding. This practice is based largely on anecdotal experience and extrapolated from limited data in cardiac surgery. Premature cessation of aspirin and/or clopidogrel following coronary artery stenting, however, has been associated with acute stent thrombosis, myocardial infarction, and death. We searched PubMed for English language articles published from 1960 to 2012, using the keywords aspirin, clopidogrel, surgery, general, vascular, genitourinary, thoracic, orthopedic, ophthalmologic, dermatologic, endoscopy, colonoscopy, cardiac device implantation, pacemaker, defibrillator, bronchoscopy, bridging, bleeding complications, and transfusion, including various combinations. s were reviewed to confirm relevance, and then the full articles were extracted. References from extracted articles were also reviewed for relevant articles. Literature regarding perioperative clopidogrel continuation is predominantly composed of small, nonrandomized data, but suggests that most noncardiac surgeries or procedures can be performed safely while patients are taking clopidogrel. In this article, we review the current best evidence on the risk for bleeding with clopidogrel therapy in noncardiac surgery, summarize recent guidelines on appropriate duration of DAPT, and make recommendations on the management of perioperative DAPT.
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Affiliation(s)
- Jonathan B Finkel
- Department of Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Peribulbar block in patients scheduled for eye procedures and treated with clopidogrel. J Anesth 2012; 26:779-82. [DOI: 10.1007/s00540-012-1406-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 04/20/2012] [Indexed: 12/21/2022]
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