When to stop antiplatelets & anticoagulants before VR Surgery?

High thromboembolic risk conditions – mechanical heart valves, venous thromboembolism last 3 months, AF with previous stroke

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High bleeding risk procedure – diabetic vitrectomy, retinectomy procedures, surgery for vascular lesions, scleral buckle (esp with external drainage)

Antiplatelets (eg. aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole, abciximab):

• Monotherapy – not stopped

• Dual therapy – little evidence

• Little evidence based for stopping 7-10 days

• Beware clopidogrel & prasugrel – if stopped, clopidogrel is for 7 days ad prasugrel for 10 days.

Anticoagulant (warfarin):

• Not stopped if therapeutic

• Defer elective surgery if above therapeutic range for patient

• Risk of bleeding similar or lower than antiplatelets

NOAC - novel oral anticoagulants (eg. rivaroxaban, apixaban, dabigatran)

• High thromboembolic risk / high bleeding risk procedure – consider bridging therapy (consult physician) or continue NOAC

• High thromboembolic risk / moderate bleeding risk procedure – continue NOAC or bridging therapy (consult physician)

• Moderate thromboembolic risk / high bleeding risk procedure – if normal renal function (stop 2 days prior); if poor renal function (stop 4 days prior)

• Moderate thromboembolic risk / moderate bleeding risk procedure – stop 1 day before

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If concern regarding stopping medication, consult with physicans.

Reference:

Patel R, Charles S, Jalil A. Antiplatelets and anticoagulants in vitreoretinal surgery, with a special emphasis on novel anticoagulants: a national survey and review. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2017 Jul;255(7):1275-1285.