Bleeding Complications in Both Anticoagulated and Nonanticoagulated Surgical Patients

The Role of Blood Pressure Control in Prevention of Hematoma After Blepharoplasty

INTRODUCTION

Hematoma formation after blepharoplasty is serious and potentially vision-threatening, with hypertension being the primary risk factor. The aim of this paper is to assess perioperative blood pressure trends and rates of complication in patients undergoing a strict blood pressure protocol designed to keep perioperative systolic blood pressure below 120 mmHg.

METHODS

A retrospective chart review was performed of 32 patients undergoing face lift with conomitant blepharoplasty from January 2015 to July 2018. For each patient blood pressure readings obtained before, during, and after surgery were reviewed. Two-sample one-tail T-tests were performed, and p values less than 0.05 were considered statistically significant.

RESULTS

The mean systolic blood pressure (SBP) for all patients was highest intraoperatively. Patients with known hypertension had higher mean SBPs than patients without hypertension across all phases of care, with a statistically significant difference in immediate preoperative SBP (p=0.05). Males had a higher average blood pressure immediately postoperatively (p=0.05). A previous diagnosis of hypertension in females was associated with a higher immediate preoperative SBP (p=0.07) as well as age over 65 (p=0.07). The overall rate of complications was 37.5%. No patients experienced hematoma.

CONCLUSION

This study demonstrated that keeping blood pressure below 120 mmHg after surgery was an effective method of preventing hematoma after blepharoplasty, even in patients concurrently on anti-coagulative medications. Special attention to blood pressure control should be shown to patients with known risk factors such as a previous diagnosis of hypertension, male sex, or age greater than 65.

LEVEL OF EVIDENCE III

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Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines

PURPOSE

Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.

METHODS

Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.

RESULTS/CONCLUSIONS

Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient's individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient's thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient's internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

A 10-min novel technique for involutional entropion: Mini-incisional continuous ligation everting sutures

PURPOSE

To introduce a novel technique of mini-incisional continuous ligation everting sutures for correction of involutional entropion and report the surgical outcome.

METHODS

A retrospective case series. Eighty-five eyelids of 77 patients who underwent correction of involutional lower lid entropion using mini-incisional continuous ligation everting sutures were included in this study. The medical records of patients with at least 24 months of follow-up after surgery were reviewed. We collected information on demographic and clinical characteristics, including sex, age at surgery, duration of follow-up, horizontal lid laxity, surgical outcomes, and complications. Main outcome measures were success of surgery, recurrence rate, time to recurrence, and risk factors for recurrence.

RESULTS

The median (interquartile range) age at the time of surgery was 72.0 (65.5-78.0) years and the median (interquartile range) follow-up duration was 24.0 (24.0-42.5) months. Thirty-seven eyelids (43.5%) showed horizontal eyelid laxity on a lid distraction test The surgical outcome was successful in the majority of patients (94.1%) with a recurrence rate of 5.9% in the 2 years after surgery. Only female sex was significantly correlated with recurrence of entropion (odds ratio 9.466, 95% confidence interval 1.022 to 87.670, P  =  0.048).

CONCLUSION

This novel technique is a promising surgical modality for correction of lower lid involutional entropion because of its ease of application, simplicity, compatibility with anticoagulants, and low recurrence rate.

Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery

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.

Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery

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.

Management of Anticoagulation and Antiplatelet Therapy in Glaucoma Surgery

The use of antithrombotic therapy is rising as the population of older adults grows and novel agents with wider indications emerge. Likewise, surgical treatment of glaucoma may become increasingly common as the prevalence of glaucoma increases and innovative treatment options are developed. These trends highlight the need to understand how best to manage antithrombotic therapy in the context of glaucoma surgery. This review article describes current literature on antithrombotic therapy and perioperative thromboembolic risk evaluation based on individual factors. In addition, guidance is offered on the management of antithrombotic therapy in the setting of each type of glaucoma surgery, with an emphasis on a multidisciplinary approach involving the patients' treating physicians.

Effects of Aspirin on Postoperative Bruising and Bleeding Complications in Upper Eyelid Surgery

PURPOSE

We evaluated the effects of aspirin versus placebo in patients undergoing upper eyelid blepharoplasty and/or levator advancement or plication blepharoptosis repair in this randomized, prospective study.

METHODS

Patients who presented between October 2017 and April 2019 requiring blepharoptosis repair and/or upper eyelid blepharoplasty who were taking 81 mg aspirin were randomized to receive 1 week of aspirin tablets or 1 week of placebo tablets prior to surgery. Postoperative complications, such as bleeding, hematoma, or hemorrhage, were noted as well as perioperative thromboembolic complications. Photos were obtained at the patient's first postoperative visit and later judged on bruising severity. The 2 groups were subsequently compared.

RESULTS

A total of 48 patients and 89 eyelids were evaluated in this study. Fifty-two eyelids were included in the aspirin group and 37 eyelids were included in the placebo group. There was no statistically significant difference in bruising rating between groups. There was no statistically significant difference in the number of patients who experienced mild postoperative bleeding. No patients experienced vision loss. No patients experienced a thromboembolic event. There were no patients who experienced hemorrhage, hematoma, or retrobulbar hemorrhage.

CONCLUSIONS

Continuation of aspirin does not appear to effect outcomes with respect to postoperative bruising in patients undergoing upper eyelid blepharoplasty or blepharoptosis repair. The study was not powered to determine statistical significance with regard to bleeding complications and would require a significantly higher sample size. We suggest changing the current guidelines to recommend routine continuation of low dose 81 mg aspirin before upper eyelid surgery.

Perioperative Management of Anticoagulants in Ocular Surgeries

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.

Perioperative Management of Antiplatelet Therapy in Ophthalmic Surgery

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

What Surgeons Should Know About Non-Vitamin K Oral Anticoagulants: A Review

Importance

Non-vitamin K oral anticoagulants (NOACs) are increasingly prescribed for patients to treat or prevent arterial or venous thromboembolism. The following 4 NOAC agents are approved by the US Food and Drug Administration for clinical use: dabigatran etexilate, apixaban, edoxaban tosylate, and rivaroxaban. A good understanding of these agents' pharmacologic properties is important for surgeons given their marked differences compared with warfarin sodium. This review highlights key practical issues surrounding the use of NOACs in the perioperative setting.

Observations

The PubMed and Cochrane Library databases were searched for English-language studies from May 1, 2009, until May 1, 2017, for randomized clinical trials, meta-analyses, systematic reviews, observational studies, and clinical guidelines. From a systematic review of the published literature that included 70 articles and 166 404 patients, this study identified 5 key practical issues surrounding the use of NOACs in the perioperative setting. These include patient populations for which NOAC use is indicated and contraindicated, the timing of NOAC treatment cessation before invasive interventions, management of NOAC-treated patients requiring urgent interventions, the need for "bridging," and the timing of NOAC treatment's reinitiation after invasive interventions. Important findings are as follows: NOAC agents are not recommended for patients with mechanical heart valves or advanced kidney disease (creatinine clearance, <15 mL/min); minimal to no anticoagulant effect remains when therapy with a NOAC is withheld for 48 to 72 hours before surgery in the context of normal kidney function; a reversal agent is clinically available for dabigatran, while reversal agents for apixaban, edoxaban, and rivaroxaban are under regulatory review; and laboratory testing of the anticoagulant effects of NOACs are not routinely available. There is a paucity of high-quality data on the optimal timing of NOAC cessation and resumption in the perioperative period, particularly for patients who undergo procedures with high bleeding risk.

Conclusions and Relevance

The anticoagulant effect of NOAC agents is predictable but not readily measurable in routine clinical practice. A number of uncertainties remain surrounding the use of these agents in the perioperative setting. Ongoing prospective studies and randomized clinical trials will provide greater clarity on these management issues in the near future.

Mini-incisional entropion repair for correcting involutional entropion: Full description and surgical outcome

The aim of the study was to report the surgical outcome of mini-incisional correction method to treat involutional entropion.This is a retrospective interventional case series of 46 eyelids in 31 patients with involutional entropion and significant ocular irritation. In this technique, after turning the lower eyelid inside out, threads are introduced into it through the conjunctiva close to the inferior fornix. The lower lid retractor and tarsus are then connected using threads. These threads are applied at 3 locations of the lower eyelid and tightening them results in the eyelid being everted and the correction of entropion. Surgical success was defined as no contact between the eyelashes and the globe during forced closure of the eyelids. Surgical failure was defined as persistence of the eyelashes remaining in contact with the globe or cosmetic dissatisfaction.During the mean follow-up period of 22.1 months (range, 12-34 months), 43 of the eyelids (93.5%) were successfully corrected. Two patients (3 eyelids) experienced recurrence: 1 had involutional entropion combined with a cicatricial component, and the other had blepharospasm and apraxia of eyelid opening related to Parkinsonism. No postoperative complications such as overcorrection, suture-knot exposure, or ocular irritation were observed.Our mini-incisional entropion repair is based on reinforcement of the lower eyelid retractors using transconjunctival buried sutures. This technique is a quick, simple, and predictive for involutional entropion repair, and has a high success rate.

[Management of anticoagulants in ophthalmic surgery-a survey among ophthalmic surgeons in Germany]

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.

Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review

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.

[Platelet aggregation inhibitors and anticoagulants during ophthalmic interventions]

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.

New oral anticoagulants and oculoplastic surgery

The use of oral anticoagulants is increasing because of the rising prevalence of atrial fibrillation and other cardiovascular diseases that occur in an aging population. In the last decade, several new oral anticoagulants have emerged, comprising the direct thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban and rivaroxaban. Although these new anticoagulants may not affect clear corneal cataract surgery, their use will impact the management of patients having eyelid, orbital, and nasolacrimal procedures. The objective of this review is to provide a concise and practical approach to the perioperative management of patients who require an oculoplastic procedure and are receiving these new anticoagulants.