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Editors Selection IGR 9-4
Laser and surgical treatment: Anticoagulants in glaucoma surgery
Comment by Jay Katz on:
21007 Anticoagulation therapy in glaucoma surgery, Alwitry A; King AJ; Vernon SA, Graefe's Archive for Clinical and Experimental Ophthalmology, 2008; 246: 891-896
In this study by Alwitry et al. (832) sampled glaucoma surgeons in the UK and concluded that there was no consensus on how to manage antico-agulation in patients undergoing glaucoma surgery. The balance between risking a bleeding issue, such as a suprachoroidal hemorrhage, hyphema, or subconjunctival blood in the filtration zone is weighed against the concern about a thromboemblic event, such as a cerebrovascular accident or pulmonary embolism. The majority of the surgeons who were surveyed (2/3) did not discontinue any anticoagulation prior to the operation. Only about one quarter of the glaucoma specialists consulted with the patient's hematologist or general practitioner. Clearly there is a risk of ocular bleeding that could have serious negative consequences following glaucoma surgery. If anticoagulation needs to be continued, then the surgeon can take steps to limit the risk to the patient. 1) Keep the operative time to the bare minimum especially with an open globe. 2) Keep the blood pressure from spiking. 3) Tie the scleral flap relatively tight. 4) Use an anterior chamber maintainer with constant infusion. 5) Provide meticulous hemostais with cauterization. 6) Lower the intraocular pressure immediately preoperatively with IV mannitol. 7) Vasoconstrict the ocular surface vessels with phenylephrine, apraclonidine, or brimonidine.
There needs be a case by case determination about cessation of anticoagulationWith valuable input from the general practitioner it could help decide the need for continued anticoagulation prior to surgery. There needs be a case by case determination about cessation of anticoagulation. A patient with recent thrombophlebitis is a different category of risk then another patient who takes aspirin daily because he is over 60 years of age but in good health. The paper points to the void of guidelines for the appropriate care of patients about to undergo glaucoma surgery. This is an opportune time to remedy that lack of specific directions on the use of various anticoagulants.
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