Perioperative Management of Antithrombotics During Oculoplastic Surgery
To date, there are no validated guidelines for oculoplastic surgeons regarding management of antithrombotic agents perioperatively. We have summarized recommendations from our review of the historical and current literature in oculoplastics and medicine in Table 2 and placed results from our survey of ASOPRS members regarding current practice patterns in Table 3. For patients who are anticoagulated, it is well tolerated to continue these medications perioperatively for minor procedures that pose low risk of hemorrhage. Three quarters of oculoplastics surgeons who responded to our survey practice this way. Examples of such procedures include chalazion incision and drainage and eyelid lesion removal. For surgeries with a higher risk for vision-threatening hemorrhage, such as DCR, deep orbital surgery, and postseptal eyelid surgery, the American College of Chest Physicians recommends to hold anticoagulation if the patient is at low risk for thromboembolism, defined as a less than 5% annual risk. We found in our survey that most oculoplastic surgeons recommend, in consultation with cardiologists, holding warfarin prior to ptosis and blepharoplasty (93%) and DCR (98%). For those at high risk (>5% annual risk) for thromboembolism, the American College of Chest Physicians recommends to preoperatively bridge oral anticoagulation with either UFH or LMWH. From a surgical standpoint however we recommend considering continuing oral anticoagulation rather than bridge therapy because there is a significant morbidity associated with major bleeding perioperatively with UFH and LWMH. Lovenox in particular can have high rates of clinically significant bleeding defined as patients requiring readmission and reoperation. Furthermore, there is no prospective evidence that Lovenox reduces the risk of periprocedural thromboembolism.
The management of NOACs perioperatively presents another challenge for oculoplastic surgeons. These agents have a shorter half-life than warfarin, and their onset (1–3 h) and offset of action (9–17 h) are quicker than warfarin, precluding the need to bridge patients. However, unlike warfarin, there is no standardized laboratory testing to monitor their anticoagulation effect. Moreover, renal function can affect the clearance of these agents, especially dabigatran. The patient's renal function must be checked 7 days prior to surgery, as the creatinine clearance can affect decisions regarding how far in advance the agents may have to be discontinued preoperatively. Evidence for the periprocedural management of NOACs is largely based on pharmacokinetics rather than clinical trials. The Randomized Evaluation of Long-Term Anticoagulation Therapy Trial (RELY) trial is the only trial that has compared dabigatran with warfarin and has not found significant difference in rates of bleeding periproceduraly. Based on the RELY trial, the European Heart Rhythm Association recommends discontinuation of NOAC 48 h prior to surgeries conferring high risk of bleeding. We recommend discussing patients' cases with their primary care physicians or cardiologists to ensure that the duration off of NOACs is well tolerated in the context of their respective indications for anticoagulation use. NOACs can typically be restarted 24 h postoperatively.
Regarding antiplatelet therapy, according to the ACCP, it is well tolerated to continue these agents in all patients undergoing minor oculoplastic procedures. Most physicians (75%) who responded to our survey continue antiplatelet agents for minor eyelid procedures, although interestingly a sizable number still do request disruption of antiplatelet therapy (25%). For moderate- to high-risk procedures, patients taking a single antiplatelet agent for primary prevention can discontinue the medication for 7–10 days. In contrast, those on antiplatelet therapy for secondary prevention of cardiovascular or cerebrovascular disease must continue medications perioperatively, as the risk of systemic events is much higher. If a patient is on DAPT, it is recommended to continue aspirin while holding the other agent (clopidogrel, ticlagreolor, or prasugrel). perioperatively, unless the patient has undergone coronary stenting in the previous 6 weeks (bare metal stent) or in the last 12 months (drug eluting stents). In this case, the administration of the DAPT must not be interrupted. It is well tolerated to resume antiplatelet agents within 24 h postoperatively if the surgeon has determined there is adequate hemostasis.
If a patient's cardiologist calls for the individual to remain fully anticoagulated, or if DAPT cannot be altered, oculoplastic surgeons should consider alternative surgical techniques to reduce hemorrhage. For example, Ing and Douketis suggested dacryocystectomy rather than DCR for dacryocystitis, as this does not require disturbance of the nasal mucosal vasculature. The possibility of foregoing the procedure must also be considered. Moreover, it is recommended to avoid postoperative pain control with non-steroidal anti-inflammatory drugs (NSAIDs). To further reduce the risk of vision-threatening postoperative hemorrhage, the oculoplastic surgeon should pay close attention to postoperative hypertension and provide medications to reduce actions such as vomiting and coughing.