Antithrombotic Therapy in Ophthalmic Procedures

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Article initiated by:
Henry Bair
All contributors:
Michael T Yen, MD, Henry Bair
Assigned editor:
Review:
Assigned status Up to Date
 by Michael T Yen, MD on October 8, 2025.


Antithrombotic therapy is common among patients presenting for ophthalmic care. Warfarin, direct oral anticoagulants (DOACs), and antiplatelet agents lower the risk of systemic thromboembolism but can increase peri-operative bleeding. For ophthalmologists, the central challenge is to balance the risk of sight- or life-threatening thrombosis from stopping therapy against the risk of vision-threatening hemorrhage if treatment is continued. The decision is rarely one-size-fits-all; it depends on both the systemic thrombotic risk of the individual patient and the bleeding risk of the planned procedure, which varies substantially across subspecialties.

This page offers a concise, practical framework, pairing patient thrombotic risk with the bleeding profile of common ophthalmic procedures and anesthesia techniques. It summarizes when to continue, hold, or bridge warfarin, DOACs, and antiplatelet agents, and provides typical post-operative restart timelines. Subspecialty sections cover cataract/anterior segment, glaucoma, retina, cornea/external disease, and oculoplastics/orbit/lacrimal, with pediatrics where relevant.

Definitions and Core Concepts

Anticoagulants

Anticoagulants reduce the formation of blood clots by inhibiting steps in the coagulation cascade. Vitamin K antagonists (VKAs) such as warfarin decrease the activity of clotting factors II, VII, IX, and X; peri-procedural decisions often use the international normalized ratio (INR) together with the planned procedure’s bleeding risk. Direct oral anticoagulants (DOACs) include dabigatran (direct thrombin inhibitor) and the factor Xa inhibitors apixaban, rivaroxaban, and edoxaban. Because DOACs have relatively short half-lives and varying renal/hepatic clearance, the timing of temporary interruption and resumption is usually based on kidney function and how “bloody” the operation is expected to be.[1]

Antiplatelet Agents

Antiplatelet agents act on platelet activation and aggregation. Aspirin irreversibly inhibits platelet cyclo-oxygenase-1 (COX-1), reducing thromboxane A2–mediated aggregation for the life of the platelet. P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) block ADP-mediated platelet activation. These drugs are frequently prescribed after coronary stenting, sometimes together as dual antiplatelet therapy (DAPT); interruption during the guideline-mandated DAPT period can carry substantial ischemic risk and generally requires coordination with the prescribing cardiologist.[2]

Bridging Anticoagulation

Bridging anticoagulation is the temporary use of a short-acting parenteral anticoagulant (e.g., low-molecular-weight heparin or unfractionated heparin) when an oral agent is held for surgery. For most patients with atrial fibrillation who are taking warfarin, randomized data show that routine bridging increases bleeding without reducing arterial thromboembolism; therefore, routine bridging is discouraged. For patients taking DOACs, bridging is generally not needed because these agents wear off and restart quickly.[3][1]

Reversal and Rescue Therapies

Reversal and rescue therapies are used for life-threatening bleeding or urgent surgery when delay is unsafe. Warfarin can be reversed with vitamin K and four-factor prothrombin complex concentrate (4F-PCC), according to institutional protocols.[1] Dabigatran has a specific reversal agent, idarucizumab, which can rapidly neutralize its effect in emergencies.[4] Major bleeding associated with factor Xa inhibitors can be treated with andexanet alfa, which reduces anti-Xa activity and achieves hemostasis in many cases, though thrombotic events can occur after reversal and require careful follow-up.[5]

Peri-Operative Cardiovascular Guidance

Peri-operative cardiovascular guidance relevant to ophthalmic procedures is provided by multidisciplinary societies. The 2022 CHEST guideline summarizes evidence-based timing for interruption and resumption of VKAs, DOACs, and antiplatelet agents, including recommendations against routine bridging in most atrial fibrillation patients. The 2024 AHA/ACC perioperative guideline offers a stepwise approach to noncardiac surgical care that can be adapted to ophthalmology when balancing thrombotic and bleeding risks.[1][6]

Pharmacology and Peri-Operative Timing of Key Antithrombotic Agents

This section summarizes core drug properties, typical half-lives, clearance pathways, commonly used pre-operative hold intervals stratified by kidney function and procedural bleeding risk, suggested post-operative restart windows, and reversal strategies. These are general guides for elective cases and should be individualized based on the procedure’s bleeding risk, creatinine clearance, concurrent therapies (for example, dual antiplatelet therapy), and input from the prescribing clinician. Timings are adapted from contemporary peri-operative guidance and prospective interruption schemes.[7][8]

Agent Class/mechanism Typical half-life (hours) Predominant clearance Usual pre-op hold (elective)* Typical post-op restart** Reversal/rescue
Warfarin Vitamin K antagonist (factors II, VII, IX, X) ~36–42 Hepatic Stop about 5 days before surgery; check INR on day of surgery Evening of surgery or next day if hemostasis is secure Vitamin K ± 4-factor PCC[7]
Dabigatran Direct thrombin (IIa) inhibitor ~12–17 Renal (predominant) CrCl ≥50 mL/min: hold 24–48 h; CrCl 30–49: hold 48–72 h; CrCl <30: hold 72–96 h 24 h (low-risk procedure) to 48–72 h (high-risk procedure) after surgery if hemostasis is secure Idarucizumab 5 g IV[9]
Apixaban Factor Xa inhibitor ~12 Mixed hepatic/renal CrCl ≥50: hold 24–48 h; CrCl 30–49: hold 48–72 h; consider ≥72 h for very high-risk surgery 24 h (low-risk) to 48–72 h (high-risk) after surgery if hemostasis is secure Andexanet alfa or 4-factor PCC (institutional protocol)[10]
Rivaroxaban Factor Xa inhibitor ~5–13 Mixed hepatic/renal CrCl ≥50: hold 24–48 h; CrCl 30–49: hold 48–72 h; extend for very high-risk surgery 24 h (low-risk) to 48–72 h (high-risk) after surgery if hemostasis is secure Andexanet alfa or 4-factor PCC[10]
Edoxaban Factor Xa inhibitor ~10–14 Renal (major) plus hepatic CrCl ≥50: hold 24–48 h; CrCl 30–49: hold 48–72 h; consider longer for high-risk surgery 24 h (low-risk) to 48–72 h (high-risk) after surgery if hemostasis is secure Andexanet alfa or 4-factor PCC[10]
Aspirin Irreversible COX-1 inhibitor (platelet thromboxane A2) Platelet effect ~7–10 days Hepatic Often continue for low-to-moderate risk ophthalmic procedures; consider 3–5 day hold for select high-risk orbital/oculoplastic cases after cardiology review Usually continue; if held, restart when hemostasis is secure (often within 24 h) Platelet transfusion; consider DDAVP per local protocol[7]
Clopidogrel P2Y12 receptor antagonist (irreversible) Platelet effect ~5–7 days Hepatic activation Consider 5 day hold for high-bleeding-risk surgery; avoid interruption during mandatory DAPT after stenting; coordinate with cardiology Restart once hemostasis is secure (often 24–72 h), individualized Platelet transfusion ± DDAVP; cardiology input for DAPT timing[7][11]
Prasugrel P2Y12 receptor antagonist (irreversible) Platelet effect ~7–10 days Hepatic activation Consider 7 day hold for high-bleeding-risk surgery; avoid interruption during mandatory DAPT; coordinate with cardiology Restart when hemostasis is secure; individualized Platelet transfusion ± DDAVP per protocol[7][11]
Ticagrelor P2Y12 receptor antagonist (reversible) ~7–9 (functional effect ~3–5 days) Hepatic (CYP3A4) Consider 3–5 day hold for high-bleeding-risk surgery; avoid interruption during mandatory DAPT; coordinate with cardiology Restart when hemostasis is secure; individualized Platelet transfusion may be less effective early; consider DDAVP per protocol[7]

Notes: * Match low- vs high-bleeding-risk to the ophthalmic procedure (for example, topical clear-corneal phacoemulsification versus trabeculectomy, tube shunt, or orbital surgery). ** For high-risk surgeries or tenuous hemostasis, delay restart and consider staged resumption; coordinate with cardiology or hematology when there is recent stenting, a mechanical valve, a ventricular assist device, or very recent venous thromboembolism.[7][12]

Risk Stratification Framework

Peri-operative decisions balance the patient’s risk of thrombosis against the bleeding risk of the planned ophthalmic procedure. This section provides a practical framework to pair systemic thrombotic risk (patient-level) with procedural bleeding risk (eye/orbit level), adapted from contemporary peri-operative guidance and tailored to common ophthalmic settings.[13][14]

Systemic Thrombotic Risk (Patient-Level)

For elective ophthalmic procedures, patients can be grouped by estimated risk of arterial or venous thromboembolism if antithrombotic therapy is interrupted. Examples are listed below and should be individualized with the prescribing clinician.

High

Mechanical mitral valve or multiple mechanical valves; recent venous thromboembolism or pulmonary embolism (<3 months); left ventricular assist device; atrial fibrillation with recent stroke/TIA or very high CHA2DS2-VASc score; recent coronary stent within the mandatory dual antiplatelet therapy window.

Moderate

Atrial fibrillation with intermediate risk factors; prior venous thromboembolism >3–12 months ago without additional high-risk features.

Low

Atrial fibrillation with low thromboembolic risk; remote venous thromboembolism (>12 months) without thrombophilia.

Modifiers

Renal dysfunction affecting DOAC clearance; hepatic disease; concomitant pro- or anti-thrombotic medications (for example, NSAIDs, additional antiplatelets); prior significant ocular or orbital bleeding.

Ocular/Orbital Procedural Bleeding Risk

Ophthalmic procedures vary widely in expected bleeding. The categories below reflect typical experience in clinic, ASC, and OR settings and can be adapted to institutional practice and anesthesia technique.

Risk tier Representative procedures Anticipated bleeding sites Common anesthesia Hemostatic mitigation options
Very low (office/minor) Intravitreal injection; YAG capsulotomy; SLT/ALT; PRP; punctal plugs; meibomian gland procedures; periocular botulinum; small eyelid lesion excision Conjunctival/surface oozing; subconjunctival hemorrhage; minor skin bleeding Topical; topical + cotton-tip pressure; local infiltration (skin) Lid speculum time minimization; brief pressure/compression; topical vasoconstrictor; post-procedure pressure patch/cotton-tip compression
Low Clear-corneal phaco (topical/sub-Tenon); simple pterygium; superficial keratectomy; chalazion I&D Conjunctival/episcleral oozing; lid margin bleeding; subconjunctival hemorrhage Topical; sub-Tenon cannula; local field block Sub-Tenon rather than sharp retrobulbar; epinephrine-containing local (where appropriate); bipolar cautery; meticulous wound tamponade
Moderate Trabeculotomy/MIGS; pterygium with wide dissection; DSEK/DSAEK/DMEK; strabismus; entropion/ectropion repair Hyphema; Tenon’s/conjunctival oozing; extraocular muscle bed bleeding; eyelid soft-tissue bleeding Sub-Tenon; peribulbar (selected cases); general anesthesia (pediatrics/strabismus) Controlled BP; careful tissue handling; judicious cautery; consider topical or injected tranexamic acid per institutional practice
High Trabeculectomy/tube shunt; PPV/scleral buckle; complex PK (vascularized); DCR/lacrimal; blepharoplasty/ptosis with retroseptal dissection; brow/orbital/decompression Hyphema; choroidal/suprachoroidal hemorrhage; deep orbital/lacrimal bed bleeding; postoperative hematoma Sub-Tenon preferred over sharp retrobulbar; peribulbar or general anesthesia for longer cases Pre-op planning of antithrombotic holds; meticulous hemostasis and bipolar cautery; topical vasoconstrictor; hemostatic agents; blood pressure control; postoperative hematoma surveillance protocol (rapid re-entry readiness)

At-a-Glance Decision Matrix

Peri-operative decisions should pair the patient’s thrombotic risk with the planned procedure’s bleeding risk. The matrix below summarizes common approaches for elective cases and assumes hemostasis is expected to be controllable. Individualize with the prescribing clinician, especially for recent coronary stenting (mandatory DAPT), mechanical valves, LVADs, very recent VTE, or significant renal impairment affecting DOAC clearance.[15][16][17]

Systemic thrombotic risk \\ Procedural bleeding risk Very low (office/minor) Low Moderate High
High (e.g., mechanical mitral valve; VTE/PE <3 mo; LVAD; AF with recent stroke/TIA; recent PCI within mandatory DAPT window) Continue antithrombotics. Use topical/subconj techniques; avoid sharp retrobulbar when possible. Provide local compression and counsel on subconjunctival hemorrhage. Generally continue. If a DOAC and renal function is reduced, consider a short timing adjustment (~24–48 h from last dose) in coordination with prescriber; do not interrupt DAPT during mandatory windows.[16] Avoid interruption if possible. If interruption is unavoidable, use the shortest hold compatible with hemostasis (see Table 3). Do not bridge DOACs. Consider VKA bridging only for select very-high-risk valve patients after specialist input.[15] Defer elective surgery if interruption of critical therapy is unsafe (e.g., mandatory DAPT). For urgent cases, coordinate a minimal hold (see Table 3) with cardiology/hematology and anesthesia; plan enhanced hemostasis and rescue.
Moderate (e.g., AF with intermediate risk; prior VTE 3–12 mo) Continue. Local measures as above. Usually continue. Consider a short hold for DOACs when using deeper blocks or when tissue dissection is expected; continue aspirin when feasible. Short hold for DOACs per renal function; consider holding P2Y12 when stent timing allows; continue aspirin if possible. VKA: stop ~5 d to INR target if hold is chosen. Longer hold as per Table 3. Coordinate restart plan; consider staged resumption. Continue aspirin if possible; hold P2Y12 only if outside mandatory DAPT window.
Low (e.g., AF low risk; remote VTE >12 mo without thrombophilia) Continue. Continue or consider brief hold for DOACs (24–48 h) depending on anesthesia and surgeon preference. Hold DOACs per Table 3; hold P2Y12 when safe; continue aspirin in many cases. VKA: stop ~5 d to INR goal if holding. Hold per Table 3 (longer windows); consider deferring cosmetic/elective high-risk cases until antithrombotic status optimizes.

Subspecialty-Specific Guidance

Cataract and Anterior Segment (Including Refractive/Phakic IOL)

For clear-corneal phacoemulsification performed under topical or sub-Tenon anesthesia, most patients can continue their usual antithrombotic therapy. The bleeding profile of small, avascular corneal incisions is low, and the most common finding is a self-limited subconjunctival hemorrhage when a conjunctival manipulation or injection is performed. Caution is advised with peribulbar or retrobulbar blocks, which carry a small but important risk of retrobulbar hemorrhage; when feasible, sub-Tenon cannula techniques or purely topical anesthesia can reduce this risk. Meticulous cautery, short operative times, and clear preoperative counseling about the possibility of visible bruising are helpful. Temporary holds are mainly considered when deeper tissue dissection is anticipated (for example, combined cases that add oculoplastic steps) or when there are additional systemic factors that increase bleeding risk; these decisions should be coordinated with the prescribing clinician.[18]

Glaucoma (Trabeculectomy, Tube Shunts, MIGS, Cyclodestructive Procedures)

Glaucoma filtering and drainage-implant surgeries have higher bleeding stakes than routine cataract surgery, including hyphema, suprachoroidal hemorrhage, and bleb-related hemorrhage. Many surgeons consider holding direct oral anticoagulants or P2Y12 inhibitors before trabeculectomy or tube shunt in patients whose thrombotic risk permits a brief interruption, while often continuing aspirin. Minimally invasive glaucoma surgery (MIGS) has a more heterogeneous bleeding profile; decisions should be individualized by device and extent of intraocular manipulation. Postoperatively, restarts are timed cautiously to protect bleb function and reduce the risk of delayed hemorrhage, balancing systemic needs with ocular healing.[19][20]

Medical Retina and Office-Based Procedures

For intravitreal injections and common office-based lasers (for example, panretinal photocoagulation, focal/grid), antithrombotics are generally continued. Multiple series suggest that while subconjunctival hemorrhage is more frequent on antiplatelet or anticoagulant therapy, vision-threatening hemorrhagic complications are uncommon, and holding therapy may expose patients to unnecessary systemic risk. YAG laser procedures (iridotomy and capsulotomy) and SLT are typically performed without interruption; brief post-procedure compression or pressure-patching can limit conjunctival oozing.[21][22]

Vitreoretinal Surgery

Posterior segment operations, particularly longer cases involving extensive membrane delamination, scleral buckling, or complex diabetic tractional repairs, carry risks of choroidal or orbital hemorrhage. Many surgeons individualize perioperative management by considering short holds of P2Y12 inhibitors or DOACs for the highest-risk dissections when systemic risk allows, while continuing aspirin when feasible. Anesthesia selection can mitigate block-related bleeding (favoring sub-Tenon cannula over sharp retrobulbar where appropriate), and careful control of intraoperative blood pressure and venous pressure further reduces risk.[23]

Cornea and External Disease

Surface and lamellar procedures (for example, superficial keratectomy, pterygium excision without deep dissection, endothelial keratoplasty) are often performed without interrupting antithrombotics, accepting a higher rate of manageable conjunctival bleeding. In vascularized corneas, combined cases, or complex penetrating keratoplasty, more conservative perioperative planning is reasonable. Hemostasis strategies—such as epinephrine-containing local anesthesia when appropriate, judicious bipolar cautery, and, where institutional practice supports it, topical or infiltrated tranexamic acid—may be used to limit bleeding.[24]

Oculoplastics, Orbit, and Lacrimal

Deep orbital and retroseptal eyelid surgery carry the greatest risk of clinically significant bleeding, including orbital hematoma with potential vision loss and, in sedated cases, airway compromise. For elective eyelid, eyebrow, orbital, and dacryocystorhinostomy procedures, many surgeons consider holding P2Y12 inhibitors or DOACs when the patient’s systemic risk and stent timing allow, while continuing aspirin in selected cases after cardiology input. Meticulous hemostasis, blood pressure control, and a postoperative hematoma surveillance protocol (including readiness for urgent wound exploration and lateral canthotomy/cantholysis) are essential. Sub-Tenon/local techniques and avoidance of sharp retrobulbar blocks reduce block-related hemorrhage in combined cases.[25][26]

Pediatric/Strabismus

Bleeding with pediatric extraocular muscle surgery is generally modest and manageable. When children are anticoagulated for congenital heart disease or other conditions, coordination with pediatric cardiology and hematology is important to balance systemic risk against surgical bleeding, and general anesthesia planning should account for airway and hemodynamic considerations.[27]

Anesthesia Considerations

Choice of anesthesia materially influences ocular bleeding risk in anticoagulated patients. Topical and sub-Tenon cannula techniques generally carry a lower risk of retrobulbar hemorrhage than sharp peribulbar or retrobulbar needle blocks. When regional blocks are necessary, measures that reduce venous pressure and allow early detection of bleeding—such as gentle injection, post-block compression, and immediate assessment for proptosis or pain—are recommended. Teams should be prepared for reversal or rescue strategies appropriate to the agent used, and for urgent orbital decompression when signs of orbital compartment syndrome appear.[28][29]

Technique Relative hemorrhage risk on antithrombotics Typical use Pearls to reduce bleeding
Topical only None Cataract (clear-corneal), YAG/SLT, office lasers and procedures that do not require injections Avoid unnecessary manipulation; gentle speculum use
Subconjunctival / subcutaneous (periocular) injections Very low Subconjunctival anesthesia/medication; eyelid local infiltration for minor lesion excision, biopsies, chalazion I&D skin wheal Use small-gauge needle; inject slowly; add epinephrine where appropriate; brief post-injection compression to limit oozing/subconj heme
Sub-Tenon (blunt cannula) Low Cataract, cornea, selected retina/glaucoma cases when akinesia/analgesia beyond topical is needed Prefer blunt cannula over sharp needle; slow incremental injection; post-injection compression; avoid elevated venous pressure
Peribulbar (needle) Moderate Longer cases requiring akinesia when Sub-Tenon is insufficient or not feasible Use smallest effective volume; avoid high airway/venous pressure; careful aspiration before injection; monitor closely for early bleeding
Retrobulbar (needle) Higher Select posterior segment and oculoplastic/orbital cases where deep akinesia is essential Consider alternatives in anticoagulated patients; immediate check for proptosis/pain; readiness for compartment syndrome management (lateral canthotomy/cantholysis)

Reversal and Rescue

When significant bleeding occurs or urgent surgery cannot be delayed, reversal strategies should be matched to the specific antithrombotic agent and the clinical urgency. Systemic reversal treats the underlying coagulopathy, while local/mechanical measures control the surgical field and prevent vision-threatening complications such as orbital compartment syndrome. The following guidance summarizes common approaches; dosing and protocols should follow local pathways and product labels, in coordination with anesthesia, cardiology/hematology, and transfusion medicine.[30]

Anticoagulants

For warfarin-associated major bleeding or when rapid reversal is required before urgent surgery, vitamin K combined with four-factor prothrombin complex concentrate (4F-PCC) is commonly used; vitamin K supports durable factor re-synthesis, and 4F-PCC provides rapid factor replacement. Fresh frozen plasma is slower and more volume-intensive and is generally avoided when 4F-PCC is available.[30]

For dabigatran, the specific reversal agent idarucizumab provides immediate neutralization of anticoagulant activity and is indicated for life-threatening bleeding or urgent procedures when delay is unsafe.[31]

For factor Xa inhibitors (apixaban, rivaroxaban, edoxaban), andexanet alfa reduces anti-Xa activity and can achieve hemostasis in many patients with major bleeding; thrombotic events have been reported after reversal, so prompt reassessment and resumption of anticoagulation when safe are important. Where andexanet is unavailable, some centers use 4F-PCC off-label as a pro-hemostatic measure in consultation with hematology.[32][30]

Antiplatelet Agents

In patients on antiplatelet therapy with serious bleeding, platelet transfusion may improve hemostasis, although timing relative to the last dose and the specific agent matters. Early after ticagrelor dosing, transfused platelets can be inhibited in circulation; desmopressin (DDAVP) is used by some centers as an adjunct to enhance platelet function, recognizing variable evidence and institutional differences. Decisions should be individualized and protocol-driven, with cardiology input when therapy supports a recent coronary stent.[30]

Local and Mechanical Measures

Local measures include direct pressure, elevated head position, topical vasoconstrictors (where appropriate), meticulous bipolar cautery, and wound exploration with hemostasis when bleeding persists. In eyelid and orbital surgery, rapidly expanding pain, proptosis, decreased vision, or afferent pupillary defect should prompt immediate orbital compartment syndrome management with lateral canthotomy and cantholysis while systemic reversal is arranged.[33]

Reversal agents: strategy, onset, and caveats (guide; confirm local dosing)

Drug/exposure Primary reversal strategy Typical onset Key caveats / notes
Warfarin (VKA) Vitamin K (IV) plus 4F-PCC (dose per INR/weight, institutional protocol) Minutes (PCC) for factor replacement; hours for vitamin K effect Verify INR after PCC; avoid volume overload from FFP when PCC available; ensure durable reversal with vitamin K.[30]
Dabigatran Idarucizumab 5 g IV (two 2.5 g boluses given in succession) Immediate neutralization Consider repeat dosing only in exceptional circumstances; hemodialysis also removes dabigatran if needed.[31]
Apixaban / Rivaroxaban / Edoxaban Andexanet alfa (low-/high-dose per last dose and timing); where unavailable, consider 4F-PCC per hematology Minutes to reduction in anti-Xa activity Thrombotic events reported post-reversal; resume anticoagulation when safe; follow institutional criteria for selection and dosing.[32][30]
Antiplatelets (aspirin; clopidogrel/prasugrel/ticagrelor) Platelet transfusion (timing sensitive); consider DDAVP (0.3 µg/kg IV) per protocol Variable (minutes to hours) Early after ticagrelor, transfused platelets can be inhibited; balance stent thrombosis risk; consult cardiology before interruption or reversal.[30]

Notes: Local hemostatic adjuncts (for example, topical vasoconstrictors, oxidized cellulose, fibrin sealants) may reduce field bleeding. Blood pressure control, avoidance of Valsalva, and head elevation support hemostasis. After reversal for major bleeding, reassess thrombotic risk daily and plan timely resumption of antithrombotic therapy once hemostasis is secure.[30]

Special Clinical Scenarios

Certain situations warrant additional coordination with cardiology/hematology and more conservative peri-operative planning. The guidance below summarizes common scenarios relevant to ophthalmology and aligns with contemporary cardiovascular and peri-operative recommendations.

Recent Coronary Stent on Dual Antiplatelet Therapy (DAPT)

During the mandatory DAPT period after percutaneous coronary intervention (PCI), elective high-bleeding-risk eye surgery should generally be deferred. If surgery cannot be delayed and bleeding risk is low (for example, topical clear-corneal phacoemulsification), many patients proceed while continuing aspirin and maintaining DAPT when feasible. If a P2Y12 agent must be interrupted outside the mandatory window, coordinate a plan with the cardiologist and document the earliest safe stop and prompt post-operative resumption. Bridging with short-acting intravenous P2Y12 inhibition (for example, cangrelor) has been described for exceptional cases but should be cardiology-directed.[34][35][36]

PCI scenario Mandatory DAPT window (typical) Elective low-bleeding-risk eye surgery Elective high-bleeding-risk eye surgery
Stable CAD with contemporary drug-eluting stent (DES) ~3 months (patient-specific) Often proceed on DAPT (prefer topical/sub-Tenon) Defer until outside mandatory window; if urgent, cardiology-directed plan
ACS with DES ~6–12 months (patient-specific) Usually proceed on DAPT only if truly low risk; cardiology input Defer if possible; interruption of P2Y12 within window generally unsafe
Bare-metal stent (rare today) ~1 month Usually proceed on DAPT if needed Defer until after window if bleeding risk is high

Mechanical Heart Valves and LVADs

Patients with mechanical valves or left ventricular assist devices (LVADs) are at high thromboembolic risk. Avoid interrupting warfarin without a cardiology-approved plan. For many mechanical mitral valves and certain aortic valves with additional risk factors, peri-operative heparin bridging may be considered; decisions should individualize bleeding risk of the ophthalmic procedure and availability of local rescue measures. DOACs are not indicated for mechanical valves.[37][38]

Renal Impairment

Because renal clearance affects DOAC pharmacokinetics—especially dabigatran—pre-operative hold intervals and post-operative restart timing should be lengthened as creatinine clearance declines. When CrCl is markedly reduced (for example, <30 mL/min), consider longer holds and favor low-bleeding-risk anesthesia (topical or sub-Tenon cannula) to minimize block-related hemorrhage.[38]

Dual Indications and Hypercoagulable States

Patients with multiple indications (for example, atrial fibrillation plus recent venous thromboembolism) or with thrombophilias require a more conservative approach. Elective high-risk ophthalmic procedures should be deferred when safe; if surgery proceeds, use the shortest feasible interruption consistent with hemostasis, avoid DOAC “bridging,” and coordinate a day-specific restart plan.[38][35]

Pregnancy

In pregnancy, warfarin and DOACs are generally avoided; low-molecular-weight heparin is preferred when anticoagulation is necessary. For elective ophthalmic procedures, defer when possible until postpartum or until anticoagulation can be safely modified in consultation with obstetrics and hematology.[39]

Combined Ophthalmic Procedures

Combined operations (for example, phaco-trabeculectomy or phaco-tube) have a higher bleeding profile than phacoemulsification alone. If interruption of antithrombotic therapy would be unsafe, consider staging procedures (for example, cataract first under topical/sub-Tenon anesthesia) and deferring the higher-risk filtration/implant step until antithrombotic status can be optimized. When combined surgery is necessary, plan longer DOAC holds per renal function, continue aspirin when feasible, and use meticulous hemostasis and postoperative surveillance for hyphema, suprachoroidal hemorrhage, and bleb-related bleeding.[40][35]

Patient Education and Shared Decision-Making

Peri-operative antithrombotic management should be explained in plain language, with decisions aligned to the patient’s goals and context (for example, monocular status, caregiving or travel plans, and tolerance for temporary visual changes). A brief, consistent script helps patients understand why a medicine may be continued, briefly paused, or avoided, and what the plan is for restarting. When discussing bleeding risk, emphasize that most ophthalmic procedures have low rates of vision-threatening hemorrhage; the most visible effect is often bruising or a subconjunctival hemorrhage that looks alarming but usually resolves without treatment. For higher-risk surgeries (for example, trabeculectomy, tube shunt, deep oculoplastics/orbit, lacrimal surgery), review the trade-offs explicitly and document the plan agreed upon with the prescribing clinician.

Patients benefit from clear expectations about anesthesia choices (topical or sub-Tenon cannula techniques reduce the chance of a deep block–related bleed), likely postoperative appearance, and simple steps that limit bleeding (head elevation, avoiding heavy lifting or Valsalva, gentle cold compresses per surgeon preference). Provide specific “red flag” symptoms that require immediate contact or evaluation—such as sudden eye pain, proptosis, new vision loss, afferent pupillary defect, or rapidly increasing eyelid swelling—since prompt intervention can be vision-saving in rare cases of orbital compartment syndrome. When interrupting antithrombotic therapy is necessary, confirm who will advise on the restart date, and put the date and time in writing.

For analgesia, acetaminophen is typically first-line. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase bleeding risk and should be used selectively, taking into account the procedure, concurrent antiplatelet therapy, and the patient’s gastrointestinal and renal risk; document any NSAID restrictions in the discharge instructions. Encourage patients to bring an up-to-date medication list to the day of surgery, and ensure that post-operative instructions clearly state which agents to continue, which to hold, and exactly when to resume them.[41][42]

References

  1. ↑ 1.0 1.1 1.2 1.3 Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207–e243.
  2. ↑ Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. Circulation 2022;145:e18–e114.
  3. ↑ Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 2015;373:823–833.
  4. ↑ Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015;373:511–520.
  5. ↑ Connolly SJ, Crowther M, Eikelboom JW, et al. Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 2019;380:1326–1335.
  6. ↑ Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451–e593.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  8. ↑ Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med 2019;179:1469-1478.
  9. ↑ Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015;373:511-520.
  10. ↑ 10.0 10.1 10.2 Connolly SJ, Crowther M, Eikelboom JW, et al. Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 2019;380:1326-1335.
  11. ↑ 11.0 11.1 Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. Circulation 2022;145:e18-e114.
  12. ↑ Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451-e593.
  13. ↑ Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  14. ↑ Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451-e593.
  15. ↑ 15.0 15.1 Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  16. ↑ 16.0 16.1 Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451-e593.
  17. ↑ Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a DOAC. JAMA Intern Med 2019;179:1469-1478.
  18. ↑ Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  19. ↑ Shah M, Law SK, Budenz DL, et al. Complications of glaucoma surgery: a review. Int Ophthalmol Clin 2011;51:139-163.
  20. ↑ Gedde SJ, Vinod K, Wright MM, et al. Primary open-angle glaucoma preferred practice pattern. Ophthalmology 2021;128:P71-P150.
  21. ↑ Dayani PN, Grand MG, Wolfe JD, et al. Ocular hemorrhage risk after intravitreal bevacizumab in patients on warfarin or clopidogrel. Am J Ophthalmol 2007;144:146-148.
  22. ↑ Khundkar T, Mohamed Q. Anticoagulation and the risks of intravitreal injections. Eye (Lond) 2010;24:1493-1496.
  23. ↑ Shah GK, Sharma S, Fineman MS, et al. Anticoagulation and antiplatelet therapy in vitreoretinal surgery. Retina 2008;28:131-135.
  24. ↑ Birbal RS, Baydoun L, Ham L, et al. Anticoagulant and antiplatelet therapy in endothelial keratoplasty. Cornea 2019;38:1120-1125.
  25. ↑ Patel SN, Buttanri IB, Singh AD. Perioperative management of antiplatelet and anticoagulant therapy in oculoplastic surgery. Curr Opin Ophthalmol 2012;23:422-427.
  26. ↑ Whipple KM, Korn BS, Kikkawa DO. Anticoagulation and antiplatelet therapy in periocular surgery. Ophthal Plast Reconstr Surg 2010;26:280-285.
  27. ↑ de Alba Campomanes AG, Binenbaum G. Perioperative considerations in pediatric ophthalmology. Curr Opin Ophthalmol 2010;21:367-372.
  28. ↑ Edge R, Navon S. Retrobulbar hemorrhage after retrobulbar block: early recognition and management. J Clin Anesth 1999;11:601-604.
  29. ↑ Marques FF, Junior JBS, Silva LM, et al. Sub-Tenon anesthesia: a safe alternative to retrobulbar/peribulbar blocks. Arq Bras Oftalmol 2010;73:197-201.
  30. ↑ 30.0 30.1 30.2 30.3 30.4 30.5 30.6 30.7 Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  31. ↑ 31.0 31.1 Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015;373:511-520.
  32. ↑ 32.0 32.1 Connolly SJ, Crowther M, Eikelboom JW, et al. Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 2019;380:1326-1335.
  33. ↑ Edge R, Navon S. Retrobulbar hemorrhage after retrobulbar block: early recognition and management. J Clin Anesth 1999;11:601-604.
  34. ↑ Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. Circulation 2022;145:e18-e114.
  35. ↑ 35.0 35.1 35.2 Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451-e593.
  36. ↑ Angiolillo DJ, Goodman SG, Bhatt DL, et al. Antiplatelet therapy in patients with coronary stents undergoing surgery. Circulation 2017;136:1248-1265.
  37. ↑ Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021;143:e72-e227.
  38. ↑ 38.0 38.1 38.2 Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  39. ↑ Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv 2018;2:3317-3359.
  40. ↑ Gedde SJ, Vinod K, Wright MM, et al. Primary open-angle glaucoma preferred practice pattern. Ophthalmology 2021;128:P71-P150.
  41. ↑ Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: American College of Chest Physicians guideline. Chest 2022;162:e207-e243.
  42. ↑ Thompson A, Fleischmann KE, Glance LG, et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150:e451-e593.
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