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Perioperative Risks of Antiplatelet and Anticoagulant Drugs in Vitreoretinal Procedures.

by Dimosthenis Mantopoulos, MD; Demetrios G. Vavvas, MD, PhD; and Howard F. Fine, MD, MHSc A multitude of new anticoagulant and antiplatelet agents have been introduced in recent years. Although some of these agents are pharmacologically reversible, many are not. The site of metabolism and halflife differs by agent, so discontinuation parameters can vary widely. Many of our cataract surgical colleagues ignore systemic anticoagulation with impunity. After all, cataract surgery is typically a bloodless procedure. Modern transconjunctival vitreoretinal surgery, particularly macular cases including epiretinal membranes and macular holes, are much less invasive than in the past. Yet other vitreoretinal procedures, such as scleral buckling or vitrectomy for diabetic tractional retinal detachment, can have dire consequences with significant bleeding. Evidence-based guidance is needed. In this edition of Practical Retina, Dimosthenis Mantopoulos, MD, from Ohio State University, and Demetrios G. Vavvas, MD, PhD, from the Massachusetts Eye and Ear Infirmary, provide a roadmap for the vitreoretinal surgeon to navigate the new landscape of anticoagulant and antiplatelet agents. They provide a handy guide regarding the metabolism and discontinuation parameters for these medications and delve into the available literature regarding their use and risks during ophthalmic surgery. Vitreoretinal surgeons are frequently faced with the preoperative decision of whether to hold an anticoagulant or antiplatelet agent. In collaboration with the patient’s primary medical team, the surgeon must balance the urgency of the case, the likelihood of intraoperative hemorrhage, and the systemic risks to holding the medication. Therefore, this review by Drs. Mantopoulos and Vavvas is sure to be of high interest to the vitreoretinal surgical community. Thanks to the latest technical advances that have made vitrectomy surgery a much safer, less-invasive, and faster procedure, its frequency has increased by 31% during the last decade. The incidence of vitrectomy surgery, according to a recent populationbased study, was 1.92 per 1,000 enrollees.1 At the same time, the use of antiplatelet (AP) drugs (eg, aspirin, and clopidogrel [Plavix; Bristol-Myers Squibb, New York, NY]) and anticoagulant (AC) drugs (eg, heparin, warfarin, rivaroxaban [Xarelto; Janssen, Beerse, Belgium], apixaban, and dabigatran [Pradaxa; Boehringer Ingelheim, Ridgefield, CT]) has dramatically increased in older adults,2-5 the population most common to undergo vitreoretinal surgery. Given the high frequency of use and inherent risks of these medications, other surgical specialties have established guidelines to optimize perioperative management.6,7 However, in ophthalmology, there are conflicting data about the sequelae of these drugs,8-10 and a final consensus has not yet been reached, with the exception possibly of in the subspecialty of oculoplastics.11 No definitive guidelines have been published related to perioperative management of anticoagulants in the field of vitreoretinal surgery, but according to a study conducted in Britain, 81% of the surgeons would consider stopping warfarin prior to vitreoretinal surgery based on the international normalized ratio (INR),12 and Chandra et al. found that use of oral anticoagulants was a risk for suprachoroidal hemorrhage.13 Yet a study by Ryan et al.14 of 85 patients with unsuspended antiplatelet or anticoagulant therapy in the perioperative period suggested that one can safely continue treatment since none of the 85 patients experienced uncontrolled hemorDimosthenis Mantopoulos