1. J Cataract Refract Surg 2010; 36:1115-1119 여의도 성모병원 R3 정연웅/Pf. 정성근
Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract surgery
J Cataract Refract Surg 2010; 36:
여의도 성모병원
R3 정연웅/Pf. 정성근

2. Introduction
Patients receiving long-term antiplatelet and anticoagulant medications
When the need for intraocular surgery arises
Continue medication → a risk for serious bleeding complications
Discontinue medication → a risk for thromboembolic complications
Little consensus on the appropriate perioperative treatment for long-term aspirin & warfarin therapy group
This study compared
In patients continuing & discontinuing antiplatelet or anticoagulant medication
After phacoemulsification & IOL implantation
The incidence
Hemorrhage & nonhemorrhagic complications
Visual course

3. Patients and Methods Patients selection
Taking warfarin, aspirin, or both for 6 months or longer
Between April 2006 and March 2008
Before April 2007, all discontinued the drugs before surgery
Discontinuataion group
Stopped therapy 1 week before surgery
Resumed the therapy 2 days postoperatively
After April 2007, all maintained the treatment
Maintenance group

4. Patients and Methods Surgical technique
A superior sclerocorneal incision after scleral cauterization
Sub-Tenon anesthesia of lidocaine 2.0%
A standard phacoemulsification technique
A 3-piece hydrophobic acrylic IOL implantation
(acrySof MA30BM, alcon, Inc.)
Sodium hyaluronate 1.0%(Healon) as viscosurgical device
Postoperatively, both groups were given
Topical levofloxacin
Dexamethasone
Diclofenac / 3 times a day for 2 weeks, tapered over 2 months

5. Patients and Methods Evaluation of outcomes Before surgery
Ocular and systemic history
Slit lamp biomicroscopy
Visual acuity
Physical examination
Dilated funduscopy
Determine the presence of retinal, vitreous and choroidal/suprachoroidal hemorrhages
Intraocular pressure(IOP) by Goldmann applanation tonometry
Corrected distance visual acuity(CDVA); logMAR values

6. Patients and Methods After surgery
Reviewed at 1 and 3 days, 1 week, and 1 month
General complications
Cerebral events(eg. TIA, cerebral infarction, and hemorrhage)
Cardiovascular events(eg. DVT, myocardial ischemia, MI)
Hemorrhagic complications
Subconjunctival hemorrhage
Hyphema
Retinal, vitreous, and choroidal/suprachoroidal hemorrhage
IOP
CDVA

7. Patients and Methods Statistical analysis
Students t-test for evaluating continuous variables
Paired t-test for evaluating the differences in IOP between the follow-up intervals
Chi-square test, Fisher exact test or Spearman rank correlation for evaluating categorical variables

8. Results Before surgery Group Parameter maintenance Discontinuation
P Value
Patients, n
173
182 -
Eyes, n
273
285
Age(y)
Mean ± SD
Range
73.3 ± 8.6
46~88
74.7 ± 7.4
48~90
.1005
Sex, n
Female
Male 95 78 97 85
.7599
CDVA
Decimal
Mean logMAR ± SD
0.314
0.503 ± 0.298
0.346
0.461 ± 0.288
.0896
Nuclear sclerosis
2.2 ± 0.6
0~5
2.3 ± 0.7
.0698
Administration, n(%)
Warfarin only
Aspirin only
Both
39 (63)
124 (198)
10 (15)
36 (59)
137 (213)
9 (15)
PT-INR
1.94 ± 0.77
1.87 ± 0.62
.6304

9. Results Complication Hemorrhagic Nonhemorrhagic Eyes, n (%) P Value
Maintenance
Discontinuation
Hemorrhagic
Subconjunctival hemorrhage
Microscopic hyphema 1 d postop
Dot retinal hemorrhage
47 (16.1)
8 (2.9)
3 (1.1)
31 (10.8)
5 (1.8)
2 (0.7)
.0309
.3572
.6187
Nonhemorrhagic
Intraoperative
Early perforation
CCC tear
Posterior capsule repture
Vitreous loss
Early postoperative
IOP spike
Corneal edema
10 (3.7)
4 (1.5)
6 (2.2)
11 (5.9)
8 (2.8)
13 (4.6)
.6884
.5673
.6616
.9578
.7064
.7568
Subconjunctival hemorrhage is significantly more eyes in the maintenance group.
Within 1 week of surgery, all bleedings had stopped without affecting visual acuity.
All nonhemorrhagic complications were self-limiting.

10. Results Postoperative day CDVA Group P Value Maintenance
Discontinuation
1 week
Mean logMAR ± SD
± 0.328
± 0.331 .2
1 month
± 0.315
± 0.318 .3

11. Discussion Subconjunctival hemorrhage Hyphema and retinal hemorrhage
The incidence was significantly greater in the maintenance group than in the discontinuation group.
The hemorrhage were self-limiting in both groups.
Hyphema and retinal hemorrhage
Patients who continued therapy had a higher incidence than those who discontinued therapy.
But, the difference was not significant.
Therefore, maintaining an antiplatelet or anticoagulant regimen during the perioperative period does not significantly increase the incidence of potentially sight-threatening complications associated with phacoemulsifiaction.

12. Discussion
The Cataract National Dataset electronic multicenter audit of 55,567 cataract surgeries
Found an association between
continuous anticoagulant treatment and
significant increases in minor complications of sharp-needle and sub-Tenon cannula local anesthesia
However, the treatments
Not associated with potentially sight-threatening complications related to local anesthesia or intraoperative hemorrhages

13. The Cataract National Dataset electronic multicenter audit

14. The Cataract National Dataset electronic multicenter audit

15. Discussion In addition, Gauba et al. found
Controlled localized bipolar conjunctival cautery before sub-Tenon anesthesia injections can significantly reduce the frequency of subconjunctival hemorrhage in patients taking warfarin or aspirin.
Dunn and Turpie found no significant difference in the thromboembolic event rate between different perioperative management.
Thromboembolic event
Continuation; 0.6%
Discontinuation; 0.0%, 0.6%(with LMWH administration)

17. Discussion Limitation The design was nonrandomized
The sample was relatively small
The analytical power was not great enough to detect small differences that might have been present.
A large-scale randomized study would be required
To determine the safety of continuous antiplatelet and anticoagulant treatment associated with phacoemulsification and IOL implantation.

18. Discussion
Summary
The incidence of subconjunctival hemorrhage at the time of phacoemulsification was significantly higher.
No significant differences between the 2 groups in the incidence of intraoperative or postoperative complication
To confirm these observations, a study with a larger population is required.