This retrospective review shows that patients may safely undergo vitreoretinal surgery while maintaining therapy with novel oral anticoagulants (NOACS) such as dabigatran, rivaroxaban, prasugrel and apixaban.
NOACS are desirable because they act quickly, effectively and don’t require regular blood monitoring and diet restrictions. However, the safety of NOACS during vitreoretinal surgery, categorized as “high risk” for hemorrhagic complications, has not been established.
Of 33 patients (36 eyes) taking oral anticoagulants in this review, none experienced retrobulbar, suprachoroidal or subretinal hemorrhage during surgery. However, 4 eyes (11.1%) developed postoperative vitreous cavity hemorrhage, 2 of which required repeat surgical intervention, while 2 eyes cleared spontaneously. Based on these results, the authors conclude that “patients may safely undergo vitreoretinal surgery while maintaining therapy with rivaroxaban, apixaban, dabigatran, and prasugrel.”
A 2015 meta-analysis including all phase 3 randomized, controlled clinical trials also found NOACS carry no greater risk for intraocular bleeding compared with other antithrombotics.
In an accompanying editorial, Drs. Andrew McClellan, Harry Flynn and Steven Gayer discuss the delicate balance vireoretinal surgeons must achieve in their decision to continue or suspend antithrombotics, taking into consideration the duration of their discontinuation and use of bridging anticoagulation therapy with heparin or enoxaparin.
These judgments are made in conjunction with the patient’s internist or cardiologist. The prescribing physician needs to evaluate the impact on the patient with respect to the thrombogenic condition being managed, and the surgeon must evaluate the impact with respect to the underlying ophthalmic disease and surgical procedure.