Current Anaesthesia & Critical Care 21 (2010) 158e163

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Current Anaesthesia & Critical Care

journal homepage: www.elsevier.com/locate/cacc

FOCUS ON: OPHTHALMIC ANAESTHESIA

Loco-regional anaesthesia for ocular surgery: Anticoagulant and antiplatelet drugs

Stephen J. Mather a, *, K.-L. Kong b, Shashi B. Vohra b
a
Consultant in Anaesthesia and Perioperative Medicine, Bristol Eye Hospital, University Hospitals Bristol, Lower Maudlin Street, Bristol BS1 2LX, United Kingdom
b
Consultant in Anaesthesia, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, United Kingdom

s u m m a r y
Keywords: Many patients undergoing ophthalmic surgery have significant co-morbidity. Many take anticoagulant or
Local anaesthesia antiplatelet drugs. Stopping these drugs in patients with heart or vascular disease may result in death
Orbital blocks
from a thromboembolic episode. The risk of this must be balanced against the risk of bleeding. In general,
Anticoagulant therapy
Antiplatelet medications
the risks of stopping these drugs outweigh the risks of ophthalmic surgery, which is in most cases
Complications confined to the eye. The majority of eye surgery is now performed under local anaesthesia (LA). There is
no strong evidence currently to favour blunt cannula techniques such as sub-Tenon’s block over tradi-
tional sharp needle peribulbar block in patients on anticoagulant or antiplatelet therapy. Most studies are
too small to detect a significant difference when comparing patients on anticoagulant or antiplatelet
medication with those that are not, but the incidence of significant sight threatening haemorrhagic
complications appears to be very low for cataract surgery, of the order of 3 per 10,000 operations.
There is some concern that drug and food interactions may affect anticoagulation with warfarin and it
is recommended that the International Normalized Ratio (INR) be measured as close to the time of
operation as possible.
Conclusions reached for ambulatory cataract surgery may not apply to more invasive and complex
operations.
Ó 2010 Elsevier Ltd. All rights reserved.

1. Cataract surgery topical e intracameral LA. Only a small number of LA cataract

The most commonly performed adult ophthalmic surgical
procedure by far is that of cataract extraction, usually by phacoe-
mulsification. In the UK the number of cataract operations per-
formed annually has increased from 105,000 in 1990 to 287,000 in
2005e2006.1,2 The vast majority of these patients are elderly with
a higher incidence of associated systemic disease such as coronary
artery disease and are often on anticoagulants or antiplatelet
medication. At the same time there has been a steady increase in
the use of local anaesthetic (LA) techniques for cataract surgery and
this had grown from 46% in 19901 to 96% in 2003.3
2. Review of the literature
2.1. Local anaesthetic techniques and complications
Recently there has been a move away from sharp needle tech-
niques towards sub-Tenon’s and, to a lesser extent, topical alone or
* Corresponding author at: Bristol Medical Simulation Centre, Level 5, Education
Centre, Upper Maudlin Street, Bristol BS2 8AE United Kingdom. Tel.: þ44 (0) 117
9282163; fax: þ44 (0) 117 3420123.
E-mail addresses: stephen.mather@doctors.org.uk (S.J. Mather), k-l.kong@swbh.
nhs.uk (K.-L. Kong), shashi@vohra.org.uk (S.B. Vohra).
operations in the late 1990’s were performed using sub-Tenon’s
block (6.7% reported in 1999).4 Ten years on this has increased to
become the preferred technique in many hospitals although there is
a wide variation of anaesthetic technique amongst ophthalmology
centres with some centres almost exclusively favouring one anaes-
thetic technique or another. There are, however, still reports of life
threatening and sight threatening complications, estimated at 3.4
per 10,000 in 1996.5 This was probably an under estimate due to
under-reporting. The recent trend towards sub-Tenon’s block rather
than sharp needle techniques is probably because it is perceived to be
safer in terms of serious complications although the evidence for
this is not conclusive. A study of 6000 sub-Tenon’s blocks in New
Zealand found a very low complication rate, and the technique
replaced sharp needle blocks in Auckland.6 Certainly retrobulbar,
intraconal block is now very rarely used in the UK (3.5% of all LA in
2007),3 but peribulbar block with a 25 mm (1 inch) needle can place
the needle retrobulbar although still extraconal: a so- called “peri-
cone” block. The optic nerve may be at less risk but the risk of
damage to blood vessels and extraocular muscles remains.
It must be emphasized that there have been no large random-
ized controlled trials to compare these LA techniques. Most reports
are based on the examination of historical data recording
complications.

0953-7112/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cacc.2010.02.011
 S.J. Mather et al. / Current Anaesthesia & Critical Care 21 (2010) 158e163
In a study by Kallio et al.,7 1383 patients had medial peribulbar or
inferolateral retrobulbar blocks. 482 (35%) were on aspirin, 76 (5.5%)
on warfarin, and 260 (19%) on non-steroidal anti-inflammatory
drugs. In total, 55 (4.0%) patients had lid haemorrhages (grades 1e3).
In 33 of these patients the haemorrhages were spot e like (grade 1).
No grade 4 haemorrhages (defined as retrobulbar haemorrhage with
increased intraocular pressure) occurred. The preoperative use of
aspirin, non-steroidal anti-inflammatory drugs or warfarin,
whether or not they had been discontinued, did not predispose to
haemorrhage associated with retrobulbar/peribulbar block.
Kumar et al. studied the frequency of haemorrhagic complica-
tions with sub-Tenon’s anaesthesia in patients on aspirin, warfarin
or clopidogrel.8
Seventy-five patients were on aspirin, 65 were on warfarin, and
40 were on clopidogrel. Seventy-five patients on no anticoagulants
were used as the control group. Subconjunctival haemorrhage
occurred in 19% in the control group, 40% in the clopidogrel group,
35% in the warfarin group, and 21% in the aspirin group. The
warfarin and clopidogrel groups had the highest incidence of
subconjunctival haemorrhage (P < 0.05).
The Cataract National Dataset Electronic Multicentre Audit9
attempted to record data about the operation, including minor
and major complications and also the technique of anaesthesia.
There were limitations in this study in that the accuracy of the data
entry relating to anaesthesia could not be ensured. A further limi-
tation of the Cataract National Dataset Electronic Multicentre audit
is that the data are derived from a limited number (12) of partici-
pating United Kingdom National Health Service Trusts and may not
therefore be representative of the practice and experience from the
rest of the country. To get truly meaningful comparative data an
extremely large number of subjects would be required. Thus we are
left with observational studies rather than a randomized controlled
trial.
In a survey of 55,567 cataract operations between November
2001 and July 2006,10 local anaesthesia was used in 95.5% of cases.
46.9% were sub-Tenon’s, 19.5% peribulbar and only 0.5% were ret-
robulbar blocks (presumably intraconal). Excluding topical and
topical e intracameral, no complications occurred in 95.6% of cases
(n ¼ 38,058). 4.3% of the patients (n ¼ 1635) suffered a ‘minor
complication’ (not sight or life threatening) and 0.066% (n ¼ 25)
suffered a ‘serious’ complication (sight or life threatening).
Subconjunctival haemorrhage occurred in 76 of 1635 eyes
(1.99%) and eyelid bruising in 85 (0.22%). Of the ‘serious’
complications, 13 occurred with needle block and 12 with sub-
Tenon’s. Peribulbar or retrobulbar haemorrhage occurred in 12
(0.032%) and suprachoroidal haemorrhage in 2 (0.005%). Of the
12 peribulbar or retrobulbar haemorrhages, 8 were the result of
needle blocks and 4 the consequence of sub-Tenon’s. This is
a statistically significant difference (P ¼ 0.009 e Fishers Exact
Test). ‘Minor’ complications were significantly more common
after sub-Tenon’s block.
2.2. Grade of anaesthetist/person performing the block
In the electronic multicentre audit by El Hindy et al.,10 the
data showed that anaesthesia was delivered by a consultant in
62.1% of cases (presuming the data to be robust, which in this
record field is open to question, since the consultant may have
only been supervising a more junior person or be the person
responsible for “distant” supervision). Data recorded on the
professional group administering the anaesthetic showed 56.7%
surgeons, 42.1% anaesthetists (including 4.5% cases of general
anaesthesia with or without LA block). Complication rates were
similar for the various professional groups and grades of doctors
delivering LA.
159
2.3. Anticoagulants and antiplatelet drugs
An unpublished study by the Audit Sub-Committee of the Royal
College of Ophthalmologists (using Eke and Thompson’s data from the
National Survey of Local Anaesthesia for Ocular Surgery) examined
54,500 local anaesthetics given in UK hospitals over a 3-month period
in the 1990’s. They estimated that 990 patients used warfarin and
5000 used aspirin, (comprehensive data being collected for 1 week
and extrapolated to the complications data collected over 3 months).
‘Severe’ orbital haemorrhage occurred 26 times. This was
defined as haemorrhage causing proptosis. 6 of these patients (23%)
were on aspirin, none on warfarin. Aspirin was associated in this
study with a small increase in risk for ocular haemorrhage.
Aspirin use is widespread with less patients taking warfarin,
clopidogrel or dipyridamole. In a UK national survey of 48,862
cataract operations11 28.1% of patients were using aspirin, 5.1%
warfarin, 1.9% clopidogrel and 1% dipyridamole. Although any
complications of sharp needle or sub-Tenon’s block were more
common in patients taking clopidogrel (8%) and warfarin (6.2%) as
compared to non-users (4.3%), no increase in potentially sight
threatening complications was found.
This study also found an increase in operative complications in
the clopidogrel group but its use was not associated with choroidal/
suprachoroidal haemorrhage or hyphaema. An unexpected finding
was an increase in posterior capsular rupture in those taking clo-
pidogrel (3.2% vs. non-users 1.77%).
The same paper reports 94 patients taking a combination of
warfarin and aspirin, 190 taking both aspirin and clopidogrel and
317 using aspirin and dipyridamole together. No information was
recorded with respect to dose, particularly of aspirin, when it could
be postulated that 300 mg may have a different effect from 75 mg.
It is well established that long-term use of anticoagulants and
antiplatelet drugs reduces the risk of thromboembolic events in
patients with atrial fibrillation and those with atherosclerotic vascular
disease, e.g., recent ischaemic stroke, recent myocardial infarction or
symptomatic peripheral vascular disease.12e16 A dilemma arises when
these patients present for cataract surgery under LA as their antico-
agulant and antiplatelet medications may predispose to the risk of
haemorrhagic complications either during administration of the LA or
during surgery itself. However, there has been no randomized
controlled trial comparing the thromboembolic events rate and the
haemorrhagic anaesthetic and surgical complications rate in cataract
surgery patients who continued or stopped their anticoagulant and
antiplatelet drugs. Such a study would require a prohibitively large
sample size of anticoagulant and antiplatelet users.
In a study of cardiac patients with prosthetic heart valves17
undergoing non-cardiac surgery, patients were converted from
warfarin to heparin (‘seamless anticoagulation’) or had their
warfarin stopped and re-instituted post-operatively. There were no
ophthalmic operations in this study but out of 235 patients (mean
age 63 years), thromboembolic and haemorrhagic events following
other types of surgery included 5 patients with cerebrovascular
accident (CVA), 11 with peripheral emboli, 10 with wound hae-
matoma and 8 with increased bleeding.
More problems were seen in patients who had mitral valve
disease and atrial fibrillation. Most complications occurred after
surgery within 10 days of re-instituting oral anticoagulant therapy.
This paper concluded that minor surgical procedures can be per-
formed safely without discontinuing anticoagulation and stresses
that thromboembolism may occur up to 1 month following surgery
despite a ‘therapeutic’ International Normalized Ratio (INR).
A large study of 19,283 cataract operations at nine centres in the
United States and Canada18 examined the risks and benefits asso-
ciated with continuation of anticoagulants or antiplatelet medica-
tion. All patients were over 50 years of age.
160 S.J. Mather et al. / Current Anaesthesia & Critical Care 21 (2010) 158e163
Patients were observed intraoperatively and for the first 7
postoperative days for the following: retrobulbar haemorrhage,
vitreous or choroidal haemorrhage, hyphaema, transient ischaemic
attack (TIA), cerebrovascular accident (CVA), deep vein thrombosis
(DVT), myocardial ischaemia and myocardial infarction.
Of these patients, 24.2% and 4.0% regularly took aspirin or
warfarin respectively. In these groups 22.5% of aspirin users and
28.3% of warfarin users discontinued the drugs preoperatively.
Rates of CVA, TIA or DVT were 1.5 per 1000 among those who
did not use aspirin or warfarin and 3.8 per 1000, among patients
who continued medication until surgery. The rate was 1 per 1000 in
the group who discontinued aspirin. There were no events among
those who discontinued warfarin.
The rates of myocardial infarction or myocardial ischaemia were
5.1 per 1000 in the aspirin group and 7.6 per 1000 in the warfarin
group of those who were routine users and who continued medi-
cation. There was no statistical difference between those who
continued and those who discontinued medication. The authors
concluded that the risk of medical or ophthalmic events associated
with cataract surgery is so low that absolute differences in risk
associated with changes in warfarin or aspirin use are minimal.
Since complication rates are so low, particularly for severe
adverse events such as catastrophic orbital haemorrhage, choroidal
haemorrhage or significant stroke or myocardial ischaemia,
evidence on which to base a recommendation for practice is small.
There is no doubt that patients with prosthetic heart valves or
recently stented coronary arteries have a high risk of possibly fatal
thrombosis if their medication is stopped.19,20 It is more difficult to
support the need for absolutely continuous antiplatelet therapy in
those who have had TIAs or stroke. However, the relative risk from
continuing the medication rather than stopping it is small and
confined to the eye.
It can therefore be proposed that where a patient is at high risk
from thromboembolic phenomena, such as those with prosthetic
heart valves, recent coronary stent (up to 1 year) and significant
thrombotic CVA, that anti-platelet and anticoagulant medication
should not be stopped. For patients with atrial fibrillation, an
assessment of the risk of stroke or death can be calculated using the
CHAD221 or Framingham22 scores which may help clinicians weigh
up the risks against the benefits of continuing or stopping antico-
agulant and antiplatelet drugs in individual patients.
The risks of operative haemorrhage threatening sight appear to
be very small and evidence from the National Cataract Database
suggests that there is no difference between sharp needle tech-
niques and sub-Tenon’s block with regard to major ophthalmic
complications. Minor haemorrhages such as subconjunctival and
lid haematoma are common but these are not of long-term concern
and do not usually delay surgery.
Even the large studies quoted here have insufficient power to
detect rare adverse events, of the order of 0.5% or less. Questions
remain, however, as to whether a difference in the incidence of
adverse events exists between peribulbar and sub-Tenon’s anaes-
thesia, which are the commonest forms of injected local anaes-
thesia in the UK, retrobulbar techniques with long, intraconal
needles having largely disappeared over the last 10 years. In
a survey of 173 consultant anaesthetist members of the British
Ophthalmic Anaesthesia Society23 sub-Tenon’s blocks were regu-
larly performed by 87.8% of respondents. The majority used a blunt
metal cannula via the inferonasal quadrant. Local anaesthetic was
placed post-equatorially by 58% of respondents and deep posteri-
orly by 16.7%. Complications included vascular and muscular
injuries, syncope and dysrhythmia, similar to complications
reported for sharp needle blocks. Although there was no agreement
on the cut off level for INR or platelets before performing the sub-
Tenon’s block, most were happy with an INR value of 3.5 or less.
3. Discussion
Most studies are too small to detect real differences between
groups taking anti-platelet drugs or anticoagulants such as
warfarin, and those who are not.
Complications reported, even in large studies, were usually
minor. Severe sight threatening haemorrhagic events are rare, of
the order of 3 per 10,000 operations.5
It is important to distinguish between the nature of haemor-
rhagic complications as the outcome is very different. Retrobulbar
haemorrhage, even if severe enough to cause proptosis, is usually
associated with a good visual outcome24,25 whereas suprachoroidal
haemorrhage is associated with a high rate of permanent visual
deficit. Fortunately, the incidence of suprachoroidal haemorrhage
appears to be much lower than that of retrobulbar haemorrhage.10
Evidence suggests that stopping antiplatelet or anticoagulant
medication, particularly in patients with atrial fibrillation, pros-
thetic heart valves or recent coronary stent carries a high risk of
thromboembolic sequelae. This risk greatly outweighs the risk of
intraocular or extraocular haemorrhage.19,20,26
Warfarin has a biologic half-life of 36e42 h. Following
commencement of warfarin therapy, it takes approximately 3e4
days for the INR to rise above 2.0. On cessation of therapy it may
require several days for the INR to fall below 2.0. One study
prospectively evaluated 22 patients with a baseline INR of 2.6, in
whom it was considered safe to discontinue warfarin therapy. The
INR fell to 1.6 at 2.7 days and 1.2 at 4.7 days. There is also concern
regarding life-threatening rebound hypercoagulability following
the abrupt cessation of anticoagulation.27
3.1. Drug interactions and INR testing
There are several medications and foods which interact with
warfarin, generally potentiating its effects. Certain drugs such as
antimicrobials, lipid-lowering agents such as simvastatin, non-
steroidal anti-inflammatory drugs (NSAIDs), selective serotonin
reuptake inhibitors, cimetidine, propranolol, amiodarone, omepra-
zole, fluorouracil, alcohol, chloral hydrate, phenytoin, influenza
vaccine, anabolic steroids and some herbal supplements are cause
for concern. Holbrook et al.27 recommend frequent INR testing
during the 2 weeks following the onset or discontinuation of treat-
ment with other medications. From a practical point of view the
preoperative timing of INR testing needs to be discussed. It would
seem sensible to have a fresh value on the day of surgery, particularly
as it is difficult to know the changes in food habits, compliance with
drugs, or change of medication in every single patient.
3.2. “Short needle” blocks
There may be an advantage to be gained by using ‘short’ e.g.,
16 mm (5/8 inch) needles for peribulbar block thus avoiding major
blood vessels, since even 25 mm (1 inch) needles may pass beyond
the posterior pole of the eye. There is as yet no large published
evidence base to support a recommendation for this. However such
‘short needle’ techniques are gaining popularity among ophthalmic
anaesthetists (personal communications).
3.3. Recommendations for practice
Recommendations are graded as follows
[A] Based on at least one randomized controlled trial as part of
a body of literature of overall good quality and consistency
addressing the specific recommendation.
 S.J. Mather et al. / Current Anaesthesia & Critical Care 21 (2010) 158e163
[B] Based on the availability of well conducted clinical studies but
no randomized controlled trials on the topic of
recommendation.
[C] Based on evidence from expert committee reports or opinions
and/or clinical experiences of respected authorities. Indicates
an absence of directly applicable clinical studies of good
quality.
3.4. Good practice points [O]
Recommended best practice based on the clinical experience of
the British Ophthalmic Anaesthesia Society (BOAS) Anticoagulant
Guideline Development Group.
1. In general, patients with prosthetic heart valves and coronary
stents should not have anticoagulant or antiplatelet agents
discontinued for cataract surgery [A].
2. We recommend continuing warfarin for routine cataract
surgery. The International Normalized Ratio (INR) must be
checked close to the time of surgery, ideally on the same day,
and the INR should be within the range that is determined by
the condition for which the patient is being anticoagulated [B].
3. Patients who self medicate or receive prescribed low-dose
aspirin may have a slightly increased risk of haemorrhage but
the benefit to be derived from stopping aspirin is, at best,
questionable. It is therefore recommended that low-dose
aspirin should not be stopped prior to cataract surgery under
LA [B].
4. Patients on clopidogrel, dipyridamole or combinations of these
with aspirin are usually on these drugs for sound medical
reasons. Withdrawal of the drugs in these circumstances may
lead to dangerous thromboembolic events. It is therefore rec-
ommended that these drugs should not be stopped for cataract
surgery [B].
5. Evidence is lacking to allow a firm recommendation to be made
with regard to technique. In particular, a recommendation for
sub-Tenon’s block over needle block cannot be supported by
weight of evidence at this time [B].
6. The use of short (less than 25 mm) needles may be inherently
safer but there is as yet no published evidence to support this.
If appropriate, topical e intracameral local anaesthetic or topical
alone is a safer alternative than needle or sub-Tenon’s block by
cannula in respect of haemorrhagic complications related to
anaesthetic technique. Such techniques, however, are not suitable for
some patients.
For operations on patients unsuitable for topical or topical e
intracameral the risk/benefit of a needle or cannula technique vs.
general anaesthesia must be considered individually for each
patient [O].
4. Other ocular surgery
There is a risk that the recommendations for ‘ambulatory cata-
ract surgery’ will be applied to more complex and invasive proce-
dures such as vitreoretinal, glaucoma and oculoplastic surgery. We
therefore need to consider them separately.
4.1. Vitreoretinal surgery
There is evidence that although anticoagulant therapy can safely
be continued for patients scheduled for vitreoretinal surgery the
literature does report complications. In a study by Chauvaud
et al.,28 60 patients (mean age 73 years) had vitreoretinal surgery
161
under sub-Tenon’s anaesthesia. 22 (36.7%) were on vitamin K
antagonists and 38 (67.3%) on antiplatelet agents (clopidogrel or
aspirin). One patient who underwent a major procedure for
complicated retinal detachment had an intraoperative subretinal
haemorrhage requiring retinectomy. No other complications
occurred. Subretinal haemorrhage is a known complication of
external drainage during scleral buckling procedures. This may
occur due to trauma to choroidal vessels, or acute hypotony.
In a study by Fu et al.,29 25 patients on systemic anticoagulation
with warfarin (International Normalized Ratio 1.5 to 3.1; median,
2.0) had vitreoretinal surgery. No intraoperative complications
were observed except in one patient. This patient had an intra-
operative subretinal haemorrhage associated with scleral buckling
and the drainage procedure.
Raj et al. have reported a spontaneous massive subretinal bleed
in a patient with background diabetic retinopathy and on treatment
with warfarin.30
The degree of anticoagulation may have a bearing on the
outcome of the surgical procedure. A retrospective study of 1737
patients undergoing pars plana vitrectomy identified 54 patients on
warfarin who underwent 57 vitreoretinal surgical procedures.31
These patients were grouped into categories depending on the
INR: Group S 1.2e1.49 (subtherapeutic), group B 1.5e1.99 (border-
line therapeutic), group T 2.0e2.49 (therapeutic) and Group HT 2.5
or greater (highly therapeutic).
There were no anaesthesia-related or intraoperative haemor-
rhagic complications. Four patients (7.0%) however suffered post-
operative haemorrhage. Two of 26 eyes (7.7%) were in group S and
two of 12 eyes (16.7%) in group HT (one patient had an INR of 2.68,
the other 2.69).
Narendran and Williamson studied seven patients undergoing
vitreoretinal surgery while on anticoagulation with aspirin and
warfarin.32 Two of the seven suffered haemorrhagic complications,
including one postoperative haemorrhagic choroidal detachment
and one recurrent vitreous haemorrhage. The authors concluded
that warfarin anticoagulation was associated with an increased risk
of haemorrhagic complications, but such a study is really too small
to draw valid conclusions.
4.1.1. Combination therapies which pose additional concern
Antiplatelet agents are increasingly prescribed in combination
or taken with non-steroidal anti-inflammatory drugs (NSAIDs),
which potentiate their action. Herbert et al. have reported four
cases of intraocular haemorrhage associated with these
combinations.33
4.2. Glaucoma surgery
Chronic anticoagulant and anti-platelet therapy have been
implicated in a statistically significant increase in the rate of hae-
morrhagic complications. Perioperative anticoagulation and a high
preoperative intraocular pressure are potential risk factors for
haemorrhagic complications in patients undergoing glaucoma
surgery. Cobb et al.34 carried out a retrospective examination of
surgical outcome of 367 consecutive trabeculectomies. 55 of the
patients were on aspirin and 5 on warfarin. Patients on aspirin were
found to have an increased incidence of hyphaema (P ¼ 0.0015) but
it did not appear to affect surgical outcome. Warfarinised patients
were found to be at a risk of serious haemorrhagic complications
compromising surgical success. The authors concluded that it was
safe to continue aspirin but recommended careful monitoring for
those on warfarin.
In another study by Law et al. three hundred and forty-seven
patients (eyes) who were on anticoagulant or antiplatelet therapy
prior to glaucoma surgery were examined.35 The haemorrhagic
162 S.J. Mather et al. / Current Anaesthesia & Critical Care 21 (2010) 158e163
complications were higher in this group than 347 control patients
(10.1% vs. 3.7%, respectively, P ¼ 0.002). Patients on anticoagulants
had a higher rate of haemorrhagic complications than patients on
antiplatelet drugs (22.9% vs. 8.0%, respectively, P ¼ 0.003). Patients
who continued anticoagulants during glaucoma surgery had the
highest rate of haemorrhagic complications when compared to
patients who discontinued anticoagulants prior to surgery or
patients who used antiplatelet therapy alone (P ¼ 0.001).
Currently, there is no definitive evidence or guideline available
with regard to discontinuation or continuation of anticoagulation/
antiplatelet therapy for glaucoma surgery. In a questionnaire
survey of glaucoma surgeons in England,36 there was diversity of
opinion, however the majority of surgeons indicated that they do
not stop warfarin or aspirin prior to glaucoma surgery.
4.3. Oculoplastic surgery
Although serious haemorrhagic complications have been shown
to be associated with oculoplastic procedures, the incidence of
these complications is low. Anticoagulation or antiplatelet therapy
needs to be tailored for individual patients. In a prospective study,37
the authors reported intraoperative bleeding prolonging surgery in
9.2% of cases. Severe bleeding with the potential to affect surgical
outcome occurred in 0.4% of procedures. There was no statistical
difference in the incidence of haemorrhagic complications among
patients on antiplatelet or anticoagulant agents, those who had
stopped these medications before surgery, and those who were not
on treatment.
4.4. Recommendations for practice
For non-cataract ocular and orbital surgery it is difficult to make
“anaesthesia- specific” recommendations based on the current
literature. However in the interest of total patient care whenever
there are any specific concerns (e.g., complicated surgery, only eye
surgery) there should be discussion between anaesthetist, surgeon,
haematologist, and patient regarding the risks and benefits of
continuing/discontinuing anticoagulants and antiplatelet drugs
and to agree an acceptable approach such as bridging therapy [O].
5. Management of orbital haemorrhage
5.1. Background
The globe and retrobulbar structures are enclosed in fascia that
is bound by the bony orbit except anteriorly. The medial and lateral
canthal tendons attach the eyelids to the orbital rim and limit the
forward movement of the globe. Retrobulbar or orbital haemor-
rhage leads to increased volume in the orbit. The orbit may
compensate for small increases in orbital volume by forward
movement of the globe and prolapse of fat. However, in a similar
way to intracranial pressure, the orbit is a low-compliance system
and follows pressureevolume relationships in which increased
tissue pressures in an enclosed space are associated with decreased
perfusion. When the pressure within the orbit exceeds central
retinal artery pressure retinal ischaemia can occur. The central
retinal artery has a degree of protection from compression by lying
within the optic nerve and because of its higher systolic blood
pressure compared to other vessels such as the prelaminar capil-
laries and peripapillary choroid and postciliary arteries, which lie
within muscle cones and enter the eye around the optic nerve to
supply the uveal tract and anterior optic nerve. Because of their
lower mean pressure they are more at risk. Blindness without
irreversible central retinal artery occlusion can also occur.
5.2. Physical signs
Proptosis
Increased intraocular pressure (IOP) e “ the hard eye”
Ecchymoses in the eyelids
Chemosis e may be severe
Ophthalmoplegia (but may also be the effect of LA)
Afferent pupillary defect (may also be the effect of LA)
Decreased visual fields (may also be the effect of LA)
Papilloedema
Central retinal artery pulsation
5.3. Investigations
No specific laboratory investigations are required.
Urea and electrolytes may be needed for a patient who requires
urgent medical treatment (e.g., acetazolamide) and additionally
haemoglobin level may be desirable for unwell patients who
require urgent surgical decompression (canthotomy).
Imaging is usually unnecessary and may delay treatment
resulting in permanent loss of vision.
5.4. Medical treatment
5.4.1. Osmotic agents
These agents decrease IOP by direct osmotic effect reducing
volume by the movement of water. However, reducing the volume
of the globe of the eye may not of itself be sufficient to significantly
lower a very high IOP, which is in turn due to very high extraocular
(orbital) pressure from the haematoma.
5.4.1.1. Mannitol. 1e2 g/kg (7.5e10.0 mL kg1) of 20% solution IV
over 30e60 min.
5.4.2. Carbonic anhydrase inhibitors
These agents decrease IOP by decreasing production of aqueous
humour in the anterior chamber.
5.4.2.1. Acetazolamide. Inhibits the enzyme carbonic anhydrase,
thus decreasing aqueous formation, which, in turn, reduces IOP.
500 mg IV bolus followed by 125e250 mg IV 4e6 h hourly or
250 mg orally 4 times daily post-operatively.
5.4.3. Steroids
Steroids are sometimes given for their anti-inflammatory and
antioxidant effects (attempt to decrease the production of free-
radicals).
5.4.3.1. Methylprednisolone. 0.5e1 g single dose given over 30 min
by IV infusion.
Beta-blockers, prostaglandin analogues and sympathomimetics
These agents may be used post-operatively. Beta-blockers
decrease IOP by decreasing production of aqueous humour. Pros-
taglandin analogues increase uveoscleral outflow. The selective
alpha2-adrenoceptor agonists brimonidine and apraclonidine can
be used for patients intolerant of beta blockers and as adjunctive
therapy.
5.5. Surgical treatment
5.5.1. Canthotomy
Primary indications for lateral canthotomy and cantholysis include
an intraocular pressure (IOP) greater than 40 mm Hg and proptosis.
 S.J. Mather et al. / Current Anaesthesia & Critical Care 21 (2010) 158e163
Secondary criteria include afferent pupillary defect, and oph-
thalmoplegia. Optic nerve head pallor, and severe pain are late signs.
Lateral canthotomy and inferior cantholysis are usually per-
formed first, but if these do not decompress the orbit, a superior
cantholysis can be done. If even further decompression is required,
anterior orbitotomy may be needed to rupture the fascial septa of
the orbital fat compartments.38,39
Anterior chamber paracentesis for retrobulbar haemorrhage has
been performed. Although this may be used to lower intraocular
pressure rapidly, it does not relieve pressure on the optic nerve
from increased intraorbital pressure and is suitable for only very
few cases.40
6. Conclusion
As the surgical outcome may be directly influenced by the
haematological status of the patient, it is important that separate
attention be given to each patient’s medical condition and the
planned surgical procedure. There is a need for close attention to
medication, anaesthetic management and surgical procedure in
patients on anticoagulant and antiplatelet drugs. Each patient
should receive individual consideration. This requires good commu-
nication and collaboration between surgeon, anaesthetist and
patient. This is particularly relevant for the more complex and
invasive procedures such as major glaucoma, vitreoretinal and
oculoplastic surgery as evidence obtained in ambulatory cataract
surgery may not be directly applicable.
Conflict of interest
None.
References
1. Courtney P. The National Cataract Surgery Survey. Eye 1992;6:487e92.
2. Department of Health Hospital Episode Statistics, www.hesonline.nhs.uk/Ease/
Servlet/Contentsener? Site ID¼1937 category ID¼193.
3. Eke T, Thompson JR. Serious complications of local anaesthesia for cataract
surgery: a one year national survey in the United Kingdom. Ophthalmology
2007;91:470e5.
4. Eke T, Thompson JR. The National survey of local anaesthesia for cataract
surgery: 1. Survey methodology and current practice. Eye 1999;13:189e95.
5. Eke T, Thompson JR. The National Survey of local anaesthesia for ocular surgery:
2. Safety profiles of local anaesthesia techniques. Eye 1999;13:196e204.
6. Guise PA. Sub-Tenon anesthesia: a prospective study of 6000 blocks. Anesthe-
siology 2003 Apr;98(4):964e8.
7. Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associ-
ated with retrobulbar/peribulbar block: a prospective study in 1383 patients. Br
J Anaesth November 2000;85:708e11.
8. Kumar N, Jivan S, Thomas P, McLure H. Sub-Tenon’s anesthesia with aspirin,
warfarin, and clopidogrel. J Cataract Refract Surg 2006;32:1022e5.
9. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, et al. The
Cataract National Database electronic multi centre audit of 55,567 operations:
updating benchmark standards of care in the United Kingdom and interna-
tionally. Eye 2009 Jan;23(1):38e49.
10. El-Hindy N, Johnston RL, Jaycock P, Eke T, Braga AJ, Tole DM, et al. The Cataract
National Database electronic multi centre audit of 55 567 operations; anaes-
thetic techniques and complications. Eye 2009 Jan;23(1):50e5.
11. Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AK, et al.
The Cataract National Database e Electronic multi centre audit of 55,567
operations: anti platelet and anti-coagulant medications. Eye 2009 Jan;23
(1):10e6.
12. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in
non-rheumatic atrial fibrillation after transient ischaemic attack or minor
stroke. Lancet 1993;342:1255e62.
13. Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B. Placebo-
controlled randomized trial of warfarin and aspirin for prevention of throm-
boembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK
Study. Lancet 1989;1:175e9.
163
14. Baigent C, Collins R, Appleby P, Parish S, Sleight P, Peto R, The ISIS e 2 (Second
International Study of Infarct Survival) Collaborative Group. ISIS e 2: 10 year
survival among patients with suspected acute myocardial infarction in
randomized comparison of intravenous streptokinase, oral aspirin, both or
neither. BMJ 1988;316:1337e43.
15. CAPRIE Steering Committee. A randomised, blinded trial for clopidogrel vs
aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:
1329e39.
16. ESPRIT Study Group, Halkes PH, Van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A.
Aspirin plus dipyridamole vs aspirin alone after cerebral ischaemia of arterial
origin (ESPRIT) randomised controlled trial. Lancet 2006;367:1665e73.
17. Carrel TP, Klingenmann W, Mohacsi PJ, Berdat P, Althaus U. Perioperative
bleeding and thromboembolic risk during non-cardiac surgery in patients with
mechanical prosthetic heart valves: an institutional review. J Heart Valve Dis
1999 Jul;8(4):392e8.
18. Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, et al. Study of
medical testing for surgery team. Risks and benefits of anticoagulant and
antiplatelet medication use before cataract surgery. Ophthalmology 2003;110
(9):1784e8.
19. Aoki J, Lansky AJ, Mehran R, Moses J, Bertrand ME, McLaurin BT, et al. Early
stent thrombosis in patients with acute coronary syndromes treated with
drug-eluting and bare metal stents: the Acute Catheterization and Urgent
Intervention Triage Strategy trial. Circulation 2009 Feb 10;119(5):687e98.
20. Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al.
The perioperative management of antithrombotic therapy: American college of
chest physicians evidence-based clinical practice guidelines (8th edition). Chest
2008 Jun;133(6 Suppl):299Se339S.
21. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Vali-
dation of clinical classification schemes for predicting stroke. JAMA
2001;285:2864e70.
22. Wang TJ, Massaro JM, Levy D, Vasan RS, Wolf PA, D’Agostino RB, et al. A risk
score for predicting stroke or death in individuals with new-onset atrial
fibrillation in the community: the Framingham Heart Study. JAMA 2003;290:
1049e56.
23. Vohra SB, Murray PI. Sub-Tenon’s block: a national United Kingdom survey.
Ophthalmic Surg Laser Imag 2008 Sep-Oct;39(5):379e85.
24. Cionni RJ, Osher RH. Retrobulbar haemorrhage. Ophthalmology 1991;98:
1153e5.
25. Krausher MF, Seelenfreund MH, Freilich DB. Central retinal artery closure
during orbital hemorrhage from retrobulbar injection. Trans Am Acad Opthal-
mol Otolaryngol 1974;78(1):OP65eOP70.
26. Rockson SG, Albers GW. Comparing the guidelines: anticoagulation therapy to
optimize stroke prevention in patients with atrial fibrillation. J Am Coll Cardiol
2004;43:929e35.
27. Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, et al.
Systematic overview of warfarin and its drug and food interactions. Arch Intern
Med 2005;165:1095e106.
28. Chauvaud D. Anticoagulation and vitreoretinal surgery. [Chirurgie vitreor-
etinienne et anticoagulants]. Bull de l Academie Nationale de Med April 2007;
191(4e5):879e84 [French].
29. Fu AD, McDonald HR, Williams DF, Cantrill HL, Ryan Jr EH, Johnson RN, et al.
Anticoagulation with warfarin in vitreoretinal surgery. Retina March 2007;27:
290e5.
30. Raj A, Sekhri R, Salam A, Priya P. Massive subretinal bleed in a patient with
background diabetic retinopathy and on treatment with warfarin. Eye July
2003;17:649e52.
31. Dayani PN, Grand MG. Maintenace of warfarin anticoagulation for patients under-
going vitreoretinal surgery. Trans Am Ophthalmol Soc. 2006 December;104:149e60.
32. Narendran N, Williamson TH. The effects of aspirin and warfarin therapy on
haemorrhage in vitreoretinal surgery. Acta Ophthalmol Scand 2003;81:38e40.
33. Herbert EN, Mokete B, Williamson TH, Laidlaw DAH. Haemorrhagic vitreor-
etinal complications associated with combined antiplatelet agents. Br J Oph-
thalmol 2006;90:1209e10.
34. Cobb CJ, Chakraborti S, Chadha V, Sanders R. The effect of aspirin and warfarin
therapy in trabeculectomy. Eye 2007;21:598e603.
35. Law SK, Song BJ, Yu F, Kurbanyan K, Yang T-A, Caprioli J. Hemorrhagic
complications from glaucoma surgery in patients on anticoagulation therapy or
antiplatelet therapy. Am J Ophthalmol April 2008;145:736e46.
36. Alwitry A, King AJ, Vernon SA. Anticoagulation therapy in glaucoma surgery.
Graefes Arch Clin Exp Ophthalmol June 2008;246:891e6.
37. Custer PL, Trinkaus KM. Hemorrhagic complications of oculoplastic surgery.
Ophthal Plast Reconstr Surg November 2002;18:409e15.
38. McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-
saving procedure. CJEM Jan 2002;4(1):49e52.
39. Burkat CN, Lemke BN. Retrobulbar hemorrhage: inferolateral anterior orbi-
totomy for emergent management. Arch Ophthalmol 2005;123(9):1260e2.
40. Yung CW, Moorthy RS, Lindley D, Ringle M, Nunery WR. Efficacy of lateral
canthotomy and cantholysis in orbital hemorrhage. Ophthal Plast Reconstr Surg
1994;10(2):137e41.