1
|
Kwon S, Lee SR, Choi EK, Lee KY, Choi J, Ahn HJ, Oh S, Lip GYH. Perioperative Management in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Minor Bleeding Risk Procedure: Rationale and Protocol for the PERIXa Study. Vasc Health Risk Manag 2024; 20:231-244. [PMID: 38774425 PMCID: PMC11107937 DOI: 10.2147/vhrm.s455530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/20/2024] [Indexed: 05/24/2024] Open
Abstract
Background While treatment interruption of non-vitamin K antagonist oral anticoagulants (NOACs) for elective surgery or procedures among patients with atrial fibrillation (AF) is becoming more prevalent, there remains insufficient evidence regarding the optimal perioperative management of NOACs, particularly procedures with minor bleeding risks. Objective This study aims to evaluate the safety and effectiveness of a simplified, standardized protocol for perioperative management of direct factor Xa inhibitors in patients, with AF undergoing procedures associated with minor bleeding risk. Methods This multicenter, prospective single-arm registry study plans to enroll patients undergoing procedures with minor bleeding risk who were prescribed direct factor Xa inhibitors for AF. The procedures with minor bleeding risk will include gastrointestinal endoscopy for diagnostic purposes, selected dental procedures, and ocular surgery for cataracts or glaucoma. For apixaban, patients will withhold the last evening dose and resume either from the evening dose of the procedure day or the following morning, depending on the bleeding risk of the patient. For edoxaban or rivaroxaban, patients will withhold only a single dose on the procedure day. The primary outcome is the occurrence of major bleeding events within 30 days. Secondary outcomes include systemic thromboembolism, all-cause mortality, and a composite of major and clinically relevant non-major bleeding events. Conclusion This study has the potential to generate evidence regarding the safety of perioperative management for patients, with AF undergoing procedures associated with minor bleeding risk. Trial Registration Clinicaltrials.gov: NCT05801068.
Collapse
Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Yoke Hong Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
2
|
Cheng SY, Wu YF, Gu XW, Zhao Q, Meng LH, Chen YX, Zhao XY. The incidence, risk factors, management and prognosis of postoperative systemic complications after ophthalmic surgery: a retrospective study at a tertiary, academic referral hospital over a decade. Ann Med 2023; 55:2262502. [PMID: 37796532 PMCID: PMC10557541 DOI: 10.1080/07853890.2023.2262502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023] Open
Abstract
PURPOSE To explore the incidence, risk factors, management and prognosis of systemic complications after ophthalmic surgeries. METHODS A retrospective review of hospitalized patients undergoing ophthalmic surgeries between 2012 and 2022 at Peking Union Medical College Hospital was performed to summarize and analyse the postoperative systemic complications. Multivariate logistic and linear regression analyses were conducted to clarify the risk factors of postoperative systemic complications and factors associated with the severity of adverse events. RESULTS A total of 34,841 patients underwent inpatient ophthalmic surgery, among which 162 systemic complications occurred in 150 patients during postoperative hospitalization. The overall incidence rate was 0.4%, with cardiovascular events (48.1%), digestive events (13.6%) and fever (12.3%) being the leading causes. About 17.3% of the cases had conditions improved after observation, 19.1% after symptomatic treatment, 54.9% had consultation with specific intervention and 8.6% were transferred to the corresponding departments for specialized treatment. For the prognosis, 93.8% had condition improved, 5.6% chose voluntary discharge without improvement, and one patient died of respiratory failure caused by postoperative pulmonary infection. The worse ADL (activities of daily living) grading, indication of primary intraocular lymphoma or intraocular tumour, surgery of simple pars plana vitrectomy (PPV), PPV with silicone oil tamponade, PPV with gas tamponade, general anaesthesia, history of diabetes mellitus (DM), chronic heart failure and digestive system disease were the risk factors positively correlated with postoperative systemic complications (p < .05). The worse ADL grading, history of DM and respiratory system disease were also positively correlated with the severity of the adverse events (p < .05). CONCLUSIONS The incidence of postoperative systemic complications was low among patients undergoing ophthalmic surgery, most were mild and could be relieved after observation, symptomatic or specialist consultation. Patients with worse ADL and history of DM should be paid extra attention.
Collapse
Affiliation(s)
- Shi-yu Cheng
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yan-fang Wu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xing-wang Gu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li-hui Meng
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - You-xin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin-yu Zhao
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
3
|
Garcia GA, Bair H, Kossler AL. Perioperative Management of Antithrombotic Medications: An Investigation into Current U. S. Ophthalmologic Recommendations. J Curr Ophthalmol 2021; 33:182-188. [PMID: 34409230 PMCID: PMC8365588 DOI: 10.4103/2452-2325.303201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose: To investigate the availability and content of educational statements or recommendations disseminated by U. S. ophthalmologic organizations regarding perioperative management of antithrombotic agents for ophthalmic and orbital surgery, given the highly variable management of these agents by U. S. ophthalmologists and limited consensus recommendations in the literature. Methods: National U. S. ophthalmic surgical organization websites were systematically examined for educational statements, which were reviewed for discussion of perioperative management of antithrombotic agents including antiplatelet and anticoagulant medications. A “statement” was defined as either: (a) a guideline directed toward ophthalmologists or (b) a surgical/clinical educational posting directed toward ophthalmologists or patients. Results: Fourteen surgical organizations were identified, with eight of these publishing clinical/surgical educational statements. A total of 3408 organizational statements were identified, with 252 (7.4%) and 3156 (92.6%) statements directed toward physicians and patients, respectively. In total, 0.3% (9/3408) of statements discussed perioperative management of antithrombotics. These accounted for 0.8% (2/252) of ophthalmologist-directed statements and 0.2% (7/3156) of patient-directed statements. The majority of patient-directed statements (57.1%, 4/7) recommended that patients discuss antithrombotic cessation with their ophthalmologists, though ophthalmologist-directed information regarding these medications was scant or absent. Conclusions: Educational material from U. S. ophthalmologic organizations regarding perioperative management of antithrombotics is notably lacking despite the fact that ophthalmic and orbital surgeries carry unique vision-threatening hemorrhagic risks. Given these risks, as well as the medicolegal consequences of hemorrhagic complications in ophthalmic surgery, increased dissemination of educational material, and consensus statements by ophthalmic surgical organizations on the perioperative management of antithrombotics may be justified.
Collapse
Affiliation(s)
- Giancarlo A Garcia
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Henry Bair
- Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
4
|
Kumar CM, Palte HD, Chua AWY, Sinha R, Shah SB, Imani F, Jalali ZM. Anesthesia Considerations for Cataract Surgery in Patients with Schizophrenia: A Narrative Review. Anesth Pain Med 2021; 11:e113750. [PMID: 34336627 PMCID: PMC8314087 DOI: 10.5812/aapm.113750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 12/28/2022] Open
Abstract
Schizophrenia is ranked among the top 10 global burdens of disease. About 1% of people meet the diagnostic criteria for this disorder over their lifetime. Schizophrenic patients can develop cataract, particularly related to age and medications, requiring surgery and anesthesia. Many concerning factors, including cognitive function, anxiety, behavioral issues, poor cooperation and paroxysmal movements, may lead to general anesthesia as the default method. Antipsychotic agents should be continued during the perioperative period if possible. Topical/regional anesthesia is suitable in most schizophrenic patients undergoing cataract surgery. It reduces potential drug interactions and many postoperative complications; however, appropriate patient selection is paramount to its success. General anesthesia remains the primary technique for patients who are considered unsuitable for the topical/regional technique. Early involvement of a psychiatrist in the perioperative period, especially for patients requiring general anesthesia, is beneficial but often under-utilized. This narrative review summarizes the anesthetic considerations for cataract surgery in patients with schizophrenia.
Collapse
Affiliation(s)
- Chandra M. Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, Yishun, Singapore
- Newcastle University Medical School, Johor, Malaysia
- Corresponding Author: Department of Anaesthesia, Khoo Teck Puat Hospital, Yishun, Singapore.
| | - Howard D. Palte
- Department of Anaesthesia, Bascom Palmer Eye Institute, University of Miami, Miami, USA
| | - Alfred W. Y. Chua
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Renu Sinha
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Shreya B. Shah
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra M. Jalali
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
5
|
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.
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Louison S, Gabrielle P, Soudry A, Meillon C, Blanc J, Béal G, Arsène S, Le Mer Y, Berrod J, Kodjikian L, Creuzot‐Garcher C. Perioperative risk of bleeding with antithrombotic agents in macular surgery: a national, prospective, multicentre study. Acta Ophthalmol 2020; 98:e991-e997. [PMID: 32279459 DOI: 10.1111/aos.14434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/15/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the risk of haemorrhagic complications in elective macular surgery between patients with no antithrombotic (AT) treatment (defined as patients with no history of AT therapy or who discontinued AT therapy) and patients who continued AT treatment during the surgery. METHODS E-case report forms were prospectively recorded in a database before vitreoretinal surgery and 1 month after. Data on patient characteristics, surgical techniques, haemorrhagic complications and antithrombotic status were collected. Patients with retinal detachment, proliferative diabetic retinopathy and previous retinal haemorrhage were excluded. RESULTS A total of 748 procedures (single procedure in one eye per patient) were performed between January and May 2019. Among them, 202 patients (27.0%) were treated with antithrombotic therapy at the time of surgery: 19.5% with antiplatelet agents (n = 146), 6.3% with anticoagulants (n = 47) including 3.2% (n = 24) patients treated with novel oral anticoagulants, 0.8% (n = 6) with anticoagulants and antiplatelet agents, and 0.4% (n = 3) with heparin. Overall, 92 patients (12.3%) developed one or more haemorrhagic complications, of which 63 (11.5%) and 29 (14.4%) were in the non-AT and AT group, respectively. The multivariate logistic regression model showed no difference between AT treatment groups regarding ocular bleeding complications (odds ratio [OR] 1.2, 95% confidence interval (CI) [0.7-2.2], p = 0.54). CONCLUSION No cases of uncontrolled or severe perioperative haemorrhage in patients continuing antithrombotic agents were reported in this selected population. For the majority of the patients taking antiplatelets or anticoagulants, these agents could be safely continued during macular surgery.
Collapse
Affiliation(s)
- Solenne Louison
- Department of Ophthalmology University Hospital Dijon France
| | - Pierre‐Henry Gabrielle
- Department of Ophthalmology University Hospital Dijon France
- Eye and Nutrition Research Group National Scientific Research Council (CNRS) National Institute of Agronomic Research (INRA) University of Burgundy Dijon France
| | - Agnès Soudry
- Department of Clinical Research and Investigation University Hospital Dijon France
| | - Cyril Meillon
- Department of Ophthalmology University Hospital Dijon France
| | - Julie Blanc
- Department of Ophthalmology University Hospital Dijon France
| | - Guillaume Béal
- Department of Anaesthesiology University Hospital Dijon France
| | - Sophie Arsène
- Department of Ophthalmology University Hospital Tours France
| | - Yannick Le Mer
- Department of Ophthalmology Rothschild Ophthalmologic Foundation Paris France
| | | | - Laurent Kodjikian
- Department of Ophthalmology Croix‐Rousse University Hospital Lyon France
| | - Catherine Creuzot‐Garcher
- Department of Ophthalmology University Hospital Dijon France
- Eye and Nutrition Research Group National Scientific Research Council (CNRS) National Institute of Agronomic Research (INRA) University of Burgundy Dijon France
| | | |
Collapse
|
8
|
McRae L, Presland A. A review of current ophthalmic anaesthetic practice. Br Med Bull 2020; 135:62-72. [PMID: 33029622 DOI: 10.1093/bmb/ldaa022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 02/13/2020] [Accepted: 04/21/2020] [Indexed: 11/13/2022]
Abstract
INTRO Ophthalmic surgery ranks among the commonest procedures performed worldwide. This review considers the range of anaesthetic techniques available to the modern ophthalmic anaesthetist, and practical considerations to evaluate in different circumstances. There is a brief summary of the main issues pertaining to the common ophthalmic subspecialties and operations. SOURCES OF DATA Pubmed. AREAS OF AGREEMENT We present a view of contemporary ophthalmic anaesthetic practice as we see it, both from current UK clinical experience, and the available published evidence. AREAS OF CONTROVERSY There is an ongoing debate about the safety of sharp needle blocks (SNBs) compared to subtenons and topical techniques, but SNBs still have a role to play, both in specific cases, and in circumstances where resources are limited. GROWING POINTS It remains a challenge to provide safe, cost effective anaesthesia to a growing patient base with ever increasing demands and medical comorbidities. There is a continuing trend towards replacing general with local anaesthesia where possible. RESEARCH Research in ophthalmic anaesthesia, as in so many areas, has been plagued by heterogeneity and small studies. A coordinated, large scale, multicentred approach to research questions in future would help to guide best practice with more certainty.
Collapse
Affiliation(s)
- Laura McRae
- Moorfields Eye Hospital NHS Foundation Trust
| | | |
Collapse
|
9
|
Widder RA, Lappas A, Rennings C, Hild M, Roessler GF, Dietlein TS. Influence of oral anticoagulation on success rates and risk of bleeding events after iStent inject implantation combined with phacoemulsification. Graefes Arch Clin Exp Ophthalmol 2020; 258:2483-2487. [PMID: 32816101 PMCID: PMC7584552 DOI: 10.1007/s00417-020-04894-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 01/14/2023] Open
Abstract
Purpose We conducted a retrospective study to evaluate the intraocular pressure (IOP) lowering effect, the success rates, and the risk of bleeding events of patients receiving an iStent inject combined with phacoemulsification under anticoagulation therapy compared with a matched control group. Methods In this retrospective study, sixty-four eyes underwent an iStent inject implantation combined with phacoemulsification at two centers. Thirty-two eyes received surgery while under anticoagulation therapy, and another thirty-two eyes served as a control group matched for visual acuity, IOP, and medication score. Success was defined as criteria A and B (IOP < 18/21 mmHg, > 20% IOP reduction, no resurgery) and criteria C (IOP ≤ 15 mmHg, IOP reduction ≥ 40%, no resurgery). The clinical goal of the study was to determine the difference between the study and control groups with respect to IOP, medication score, and the frequency of intraoperative and postoperative bleeding events. Results After a mean follow-up time of 1 year, the IOP lowered 28% from 20.1 ± 4.8 to 14.5 ± 3.7 mmHg in the group of 64 eyes. The medication score lowered 38% from 2.1 ± 1.1 to 1.3 ± 1.2. The two groups with and without anticoagulant agents did not significantly differ in postoperative IOP, medication score, success rates, or number of bleeding events. Conclusion We conclude that in cataract surgery combined with the iStent inject a discontinuation of anticoagulant agents might not be necessary. It might be a good option in glaucoma surgery when anticoagulation treatment should not be interrupted and the target pressure is not very low.
Collapse
Affiliation(s)
- Randolf A Widder
- Department of Ophthalmology, St. Martinus-Krankenhaus Düsseldorf, Gladbacher Strasse 26, 40219, Düsseldorf, Germany. .,Center of Ophthalmology, University of Cologne, Kerpener Strasse 62, 50937, Köln, Germany.
| | - Alexandra Lappas
- Center of Ophthalmology, University of Cologne, Kerpener Strasse 62, 50937, Köln, Germany
| | - Corinna Rennings
- Department of Ophthalmology, St. Martinus-Krankenhaus Düsseldorf, Gladbacher Strasse 26, 40219, Düsseldorf, Germany
| | - Matthias Hild
- Department of Ophthalmology, St. Martinus-Krankenhaus Düsseldorf, Gladbacher Strasse 26, 40219, Düsseldorf, Germany
| | - Gernot F Roessler
- Department of Ophthalmology, St. Martinus-Krankenhaus Düsseldorf, Gladbacher Strasse 26, 40219, Düsseldorf, Germany.,Department of Ophthalmology, RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Thomas S Dietlein
- Center of Ophthalmology, University of Cologne, Kerpener Strasse 62, 50937, Köln, Germany
| |
Collapse
|
10
|
A Case of Delayed-onset Hemorrhagic Choroidal Detachment After PreserFlo Microshunt Implantation in a Glaucoma Patient Under Anticoagulant Therapy. J Glaucoma 2020; 29:e87-e90. [PMID: 32568812 DOI: 10.1097/ijg.0000000000001584] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe a case of delayed-onset hemorrhagic choroidal detachment (HCD) in a patient affected by primary open-angle glaucoma (POAG) undergone PreserFlo Microshunt implantation. CASE REPORT DESCRIPTION A 76-year-old patient with POAG, under treatment with Dabigatran (a novel oral anticoagulant), underwent an uncomplicated PreserFlo Microshunt implantation in the left eye. In the first postoperative day, intraocular pressure (IOP) was 6 mm Hg, conjunctival bleb was diffuse, anterior chamber (AC) deep, and device correctly positioned. Twelve days after surgery, the patient had emergency access complaining severe ocular pain and sudden vision loss. Ophthalmological evaluation revealed shallow AC and an IOP of 50 mm Hg. The fundus examination revealed almost kissing HCD. OUTCOME Immediate topical treatment with atropine, aqueous humor suppressants, and corticosteroids was started. Because of high IOP, ocular pain, and the presence of almost kissing HCD, surgical drainage of suprachoroidal hemorrhage and removal of PreserFlo Microshunt were performed. An improvement of the clinical condition was observed in the following postoperative days, with partial resolution of the HCD and a decrease of the IOP. On the third postoperative day, there was a worsening of the HCD, with a reduction of the AC depth and IOP elevation. HCD was drained through the previously performed sclerotomies, associated with pars-plana vitrectomy and silicone-oil tamponade. HCD completely resolved during the following 6 weeks, with IOP reduction and partial improvement of visual acuity. CONCLUSION Great attention must be taken in patients with glaucoma under treatment with a novel oral anticoagulant, also when planning PreserFlo Microshunt implantation.
Collapse
|
11
|
Gotoh S, Yasaka M, Nakamura A, Kuwashiro T, Okada Y. Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding: The MARK Study. J Am Heart Assoc 2020; 9:e012774. [PMID: 32079478 PMCID: PMC7335562 DOI: 10.1161/jaha.119.012774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Optimal management of antithrombotic agents during surgery has yet to be established. We performed a prospective multicenter observational study to determine the current status of the management of antithrombotic agents during surgery or other medical procedures with bleeding (MARK [Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding] study) in Japan. Methods and Results The participants were 9700 patients who received oral antithrombotic agents and underwent scheduled medical procedures with bleeding at 59 National Hospital Organization institutions in Japan. Primary outcomes were thromboembolic events, bleeding events, and death within 2 weeks before and 4 weeks after the procedures. We investigated the relationships between each outcome and patient demographics, comorbidities, type of procedure, and management of antithrombotic therapy. With respect to the periprocedural management of antithrombotic agents, 3551 patients continued oral antithrombotic agents (36.6%, continuation group) and 6149 patients discontinued them (63.4%, discontinuation group). The incidence of any thromboembolic event (1.7% versus 0.6%, P<0.001), major bleeding (7.6% versus 0.4%, P<0.001), and death (0.8% versus 0.4%, P<0.001) was all greater in the discontinuation group than the continuation group. In multivariate analysis, even after adjusting for confounding factors, discontinuation of anticoagulant agents was significantly associated with higher risk for both thromboembolic events (odds ratio: 4.55; 95% CI, 1.67-12.4; P=0.003) and major bleeding (odds ratio: 11.1; 95% CI, 2.03-60.3; P=0.006) in procedures with low bleeding risk. In contrast, heparin bridging therapy was significantly associated with higher risk for both thromboembolic events (odds ratio: 2.03; 95% CI, 1.28-3.22; P=0.003) and major bleeding (odds ratio: 1.36; 95% CI, 1.10-1.68; P=0.005) in procedures with high bleeding risk. Conclusions Discontinuation of oral antithrombotic agents and addition of low-dose heparin bridging therapy appear to be significantly associated with adverse events in the periprocedural period.
Collapse
Affiliation(s)
- Seiji Gotoh
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Asako Nakamura
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Takahiro Kuwashiro
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Galvis V, Tello A, Carreño NI, Sánchez WA, Frederick GA, Blanco NA. Massive Hyphaema Following Laser Iridotomy in a Patient on Dual Antiplatelet Therapy (Aspirin plus Ticagrelor): Case report and literature review. Sultan Qaboos Univ Med J 2019; 19:e63-e67. [PMID: 31198598 PMCID: PMC6544073 DOI: 10.18295/squmj.2019.19.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/04/2018] [Accepted: 11/22/2018] [Indexed: 01/21/2023] Open
Abstract
Massive hyphaema presentation after a laser iridotomy is very rare. We report a 63-year-old man with ischaemic heart disease on dual antiplatelet therapy (aspirin plus ticagrelor) who was diagnosed as a primary angle-closure suspect and was to undergo a neodymium-doped yttrium aluminium garnet laser iridotomy at Centro Oftalmológico Virgilio Galvis, Floridablanca, Colombia in 2016. While performing the iridotomy in the left eye, active bleeding occurred that finally filled approximately 75% of the anterior chamber. Intraocular pressure (IOP) increased to 62 mmHg. Mannitol and a topical dorzolamide/timolol were used to control the increase in IOP. The hyphaema slowly resolved over the following week without sequelae. This case revealed that massive hyphaema can complicate laser iridotomy in patients on dual antiplatelet therapy, although this is rare. Therefore, if patients are taking aspirin and ticagrelor, it would be advisable to stop the second medication if possible. In addition, sequential application of photocoagulation and photodisruption lasers might diminish the risk of significant bleeding.
Collapse
Affiliation(s)
- Virgilio Galvis
- Department of Ophthalmology, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia.,Department of Ophthalmology, Centro Oftalmológico Virgilio Galvis, Floridablanca, Santander, Colombia
| | - Alejandro Tello
- Department of Ophthalmology, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia.,Department of Ophthalmology, Centro Oftalmológico Virgilio Galvis, Floridablanca, Santander, Colombia
| | - Néstor I Carreño
- Department of Ophthalmology, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia.,Department of Ophthalmology, Centro Oftalmológico Virgilio Galvis, Floridablanca, Santander, Colombia
| | - Walter A Sánchez
- Department of Ophthalmology, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Gabriel A Frederick
- Department of Ophthalmology, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Nicolás A Blanco
- Department of Ophthalmology, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Nagrebetsky A, Al-Samkari H, Davis N, Kuter D, Wiener-Kronish J. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 2019; 122:19-31. [DOI: 10.1016/j.bja.2018.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/19/2023] Open
|
16
|
Loukovaara S, Sahanne S, Takala A, Haukka J. Statin use and vitreoretinal surgery: Findings from a Finnish population-based cohort study. Acta Ophthalmol 2018; 96:442-451. [PMID: 29338115 DOI: 10.1111/aos.13641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Vitreoretinal (VR) surgery is the third most common intraocular surgery after refractive and cataract surgery. The impact of statin therapy on VR surgery outcomes remains unclear, despite a potentially beneficial effect. We explored the association of preoperative statin therapy and the need for revitrectomy after primary vitrectomy. METHODS Our historical, population-based, register-based, VR surgery cohort consisted of 5709 patients operated in a tertiary, academic referral hospital in Finland, during 2008-2014, covering 6.5 years. Subgroup analysis was performed as follows: eyes operated due to (i) rhegmatogenous retinal detachment (RRD), (ii) VR interface diseases (macular pucker/hole), (iii) diabetic maculopathy or proliferative retinopathy, (iv) vitreous haemorrhage, (v) lens subluxation, (vi) vitreous opacities or (vii) other VR indication. The primary end-point event was revitrectomy during a postoperative follow-up period of 1 year due to retinal redetachment, vitreous rehaemorrhage, postoperative endophthalmitis, recurrent pucker or unclosed macular hole. RESULTS Rhegmatogenous retinal detachment (RRD) was the second most frequent indication of VR surgery, including 1916 patients, with 305 re-operations with rate 0.20 (95% CI 0.18-0.23) per person-year. Statin treatment in time of operation was associated with lower risk of re-operation according to relative scale (incidence rate ratio 0.72, 95% CI 0.53-0.97), but not in absolute scale (incidence rate difference -0.58, 95% CI -4.30 to 3.15 for 100 person-years). No association with statin therapy and vitrectomy outcome was observed in the other VR subgroups. CONCLUSION Use of statin treatment was associated with a 28% lower risk of revitrectomy in patients operated due to RRD. Further randomized clinical trials are highly warranted.
Collapse
Affiliation(s)
- Sirpa Loukovaara
- Unit of Vitreoretinal Surgery; Department of Ophthalmology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Sari Sahanne
- Department of Anesthesiology and Intensive Care Medicine; Helsinki University Hospital; Helsinki Finland
| | - Annika Takala
- Department of Anesthesiology and Intensive Care Medicine; Helsinki University Hospital; Helsinki Finland
| | - Jari Haukka
- Department of Public Health; University of Helsinki; Helsinki Finland
| |
Collapse
|
17
|
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
|
18
|
Liu YC, Wilkins M, Kim T, Malyugin B, Mehta JS. Cataracts. Lancet 2017; 390:600-612. [PMID: 28242111 DOI: 10.1016/s0140-6736(17)30544-5] [Citation(s) in RCA: 526] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/27/2016] [Accepted: 02/02/2017] [Indexed: 12/11/2022]
Abstract
An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.
Collapse
Affiliation(s)
- Yu-Chi Liu
- Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore; Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore
| | - Mark Wilkins
- Department of Cornea and External Eye Disease, Moorfields Eye Hospital, London, UK
| | - Terry Kim
- Department of Cornea and External Disease, Department of Ophthalmology, Duke University, Durham, NC, USA
| | - Boris Malyugin
- Department of Cataract and Implant Surgery, S Fyodorov Eye Microsurgery State Institution, Moscow, Russia
| | - Jodhbir S Mehta
- Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore; Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore; Department of Clinical Sciences, Duke-NUS Medical School, Singapore.
| |
Collapse
|
19
|
Sun MT, Wood MK, Chan W, Selva D, Sanders P, Casson RJ, Wong CX. Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis. JAMA Ophthalmol 2017; 135:864-870. [PMID: 28687831 PMCID: PMC5710315 DOI: 10.1001/jamaophthalmol.2017.2199] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/22/2017] [Indexed: 12/11/2022]
Abstract
Importance It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin. Objective To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin. Data Sources A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles. Study Selection Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis. Data Extraction and Synthesis The PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators. Main Outcomes and Measures Intraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin. Results Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used. Conclusions and Relevance These results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.
Collapse
Affiliation(s)
- Michelle T. Sun
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Megan K. Wood
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - WengOnn Chan
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Dinesh Selva
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Robert J. Casson
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Christopher X. Wong
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, The University of Adelaide and Royal Adelaide Hospital, Adelaide
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, England
| |
Collapse
|
20
|
Martin TJ, Kerridge RK. Reply-stopping antithrombotics during regional anaesthesia and eye surgery: crying wolf? Br J Anaesth 2017; 118:805. [PMID: 28510758 DOI: 10.1093/bja/aex115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Eke T. Preoperative Preparation and Anesthesia for Trabeculectomy. J Curr Glaucoma Pract 2016; 10:21-35. [PMID: 27231416 PMCID: PMC4875731 DOI: 10.5005/jp-journals-10008-1198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/23/2015] [Indexed: 11/29/2022] Open
Abstract
Preoperative preparation should improve the likelihood of successful trabeculectomy surgery. The team can reconsider the appropriateness of the proposed surgery, and steps can be taken to maximize the chance of a good outcome. For example, adjustments to anti-hypertensive or anti-coagulant medications may be made, and topical ocular medications adjusted. Choice of anesthesia technique is of particular relevance to the trabeculectomy patient. Some anesthesia techniques are more likely to have serious complications, and glaucoma patients may be at higher risk of some sight-threatening complications, because the optic nerve is already damaged and vulnerable. Posterior placement of local anesthesia (retrobulbar, peribulbar, posterior sub-Tenon's techniques) could potentially damage the optic nerve, and thereby cause "wipe-out" of vision. Anesthesia technique may influence the likelihood of vitreous bulge and surgical difficulty. Regarding long-term control of intraocular pressure, there is no good evidence to indicate that any particular anesthesia technique is better than another. There is little high-quality evidence on this topic. The author's preferred technique for trabeculectomy is subconjunctival-intracameral anesthesia without sedation. How to cite this article: Eke T. Preoperative Preparation and Anesthesia for Trabeculectomy. J Curr Glaucoma Pract 2016; 10(1):21-35.
Collapse
Affiliation(s)
- Tom Eke
- Consultant, Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UK
| |
Collapse
|
23
|
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.
Collapse
Affiliation(s)
- Howard D Palte
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL, USA
| |
Collapse
|
24
|
Are our cornea waiting lists dynamic enough? Int Ophthalmol 2015. [PMID: 26208680 DOI: 10.1007/s10792-015-0101-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to evaluate the dynamic reality of the corneal transplant (CT) waiting list and if the CT candidates are really eager to operation. We evaluated the response of consecutive 96 CT candidates to call for operation. The age, functional visual acuity, CT indication, waiting period, and the excuse of refusal for candidates that postponed the operation were also evaluated. The patients were classified into two groups according to the availability (Group 1, available; Group 2, unavailable). To find an available candidate for transplantation of 48 consecutive corneal tissues, 96 patients had to be called. The mean age of the patients was 57.49 ± 18.75. The mean age of Group 1 and Group 2 was 54.28 ± 18.12 (13-80) and 60.44 ± 19.01 (9-88) years, respectively (p = 0.108). It was found that the call refusal was higher in patients elder than age 70 (p = 0.04). The mean time between being added to the list and the call was 22.96 ± 7.80 (9-39) months for Group 1, 27.02 ± 8.25 (9-53) months for Group 2 (p = 0.015). The estimation point for waiting period was 22 months (p = 0.044). The most common reasons of excuse were inconvenience of timing, giving up operation, and secondary health problems, whereas anticoagulant use was the most common reason for postponement. As the waiting period gets longer and CT candidates get older, they tend to give up operation. The secondary health problems and use of systemic anticoagulants are important problems that might cause postponing the CT surgery and ruin the dynamicity of the waiting lists.
Collapse
|