October 2020


New anticoagulant therapies and cataract surgery safety

by Maxine Lipner Contributing Writer

Anticoagulant agents are a necessity for many in the cataract surgery demographic, and as ophthalmologists know, these agents can present challenges in the OR. For years, this meant facing many patients on warfarin, but now newer agents, such as Pradaxa (dabigatran, Boehringer Ingelheim), Xarelto (rivaroxaban, Janssen Pharmaceuticals), and Eliquis (apixaban, Bristol-Myers Squibb), are becoming more common, according to Irina Barequet, MD. A study by Dr. Barequet and coinvestigators suggests these novel oral anticoagulants (NOACs) might be safer during cataract surgery, finding no increased risk of bleeding during uncomplicated procedures.1
Prior to this study, there were no prospective investigations of cataract surgery with these newer anticoagulants, Dr. Barequet pointed out. “We thought that we needed to assess surgeries with these new medications because a more controlled safety study should be performed, given that there were some reports of intraocular bleeding in patients treated with NOACs,” she said.
The prospective case series included 35 eyes of 25 cataract patients; none of the patients had previous ocular surgery. Since there had been reports of spontaneous intraocular bleeding in patients treated with NOACs, the researchers included only simple cataract cases. Two cases ended up requiring a Malyugin ring for intraoperative pupil expansion, and one eye required implantation of a capsular tension ring because of partial zonulolysis.
“We looked at patients’ anticoagulation levels and performed tests for blood, drawn just prior to the entrance to the OR, and we found that 85% of the patients were on therapeutic levels of NOACs,” Dr. Barequet said.
Overall, the researchers found only minor bleeding at the incision site or at the conjunctiva, and no postoperative hemorrhagic events occurred, even in cases requiring capsular tension rings.
There’s been a balance between the patients’ need for anticoagulant medication and concerns about bleeding that may occur during the surgery. “Sometimes patients are instructed to take the medicine but they don’t because of fear of bleeding,” Dr. Barequet said. “Although there are antidotes to the NOACs, they are not readily available. Sometimes if they’re at an ambulatory center, surgeons worry that if they face a hemorrhagic event, they won’t have any availability of the antidotes.”
This makes the study results all the more compelling, Dr. Barequet said. “We were able to show in a very hematologic-controlled environment, in a prospective study, that there was no increased intra- or postoperative risk in these patients,” Dr. Barequet said, adding, “There is no need to ask patients to refrain from using these medications.”
While further study is needed for complicated cases, such as those that might involve a Malyugin ring, Dr. Barequet is comfortable performing cataract surgery in those on NOACs.
There are occasional patients who are still on warfarin products to consider. “I think the minority are still on Coumadin [warfarin, Bristol-Myers Squibb]. I think there has been a big transition to the new anticoagulants,” Dr. Barequet said.
If a patient is on Coumadin, they can require more attention. Earlier studies that Dr. Barequet conducted showed that some surgeries needed to be canceled because of high anticoagulation levels in patients on Coumadin, which posed a surgical and hemorrhagic risk for some.2,3
In cases where the patient is on Coumadin, Dr. Barequet said she tries to get the anticoagulation levels 2–3 days prior to surgery and adjusts the level if it is too high.
In general, patients presenting for cataract surgery are often on complex systemic medications, Dr. Barequet said. Although cataract surgery is considered a safe, simple procedure, it still has the potential to pose risks. “It is important to have evidence-based data showing safety for physicians and also for patients to feel safe, so that they don’t need to take any risks by continuing their medications,” she concluded.

About the doctor

Irina Barequet, MD
Head of the Cornea Division
Goldschleger Eye Institute
Sheba Medical Center
Tel Hashomer, Israel


1. Barequet IS, et al. Safety of cataract surgery in patients treated with the new oral anticoagulants (NOACs). Graefes Arch Clin Exp Ophthalmol. 2019;257:2671–2676.
2. Barequet IS, et al. Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematological risk assessment. Am J Ophthalmol. 2007;144:719–723.
3.Barequet IS, et al. Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg. 2011;37:1434–1438.

Relevant disclosures

Barequet: None


: ibarequet@yahoo.com

New anticoagulant therapies and cataract surgery safety New anticoagulant therapies and cataract surgery safety
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