Evaluation of Bleeding Risk of Cataract Phacoemulsification in Patients with Long-term Aspirin Use after Percutaneous Coronary Intervention

Abstract

PURPOSE:

It is a controversial issue whether to discontinue antithrombotic drugs during the perioperative period of cataract surgery. There are few reports on the safety of long-term aspirin use after percutaneous coronary intervention (PCI). In this study, we evaluated the bleeding risk and surgical safety of cataract phacoemulsification in patients who took aspirin for a long time after PCI, so as to provide relevant evidence for this problem.

METHODS:

Retrospective analysis of the cases of cataract surgery. The incidence of bleeding-related complications in patients without history of antithrombotic drugs, patients without cardiac surgery who had taken aspirin at least 1 year for secondary prevention, and patients with long-term aspirin use 1 year after PCI were compared.

RESULTS:

A total of 81 patients (81 eyes, n = 81) after PCI (≥1 year) were collected. One hundred fifty-eight patients (158 eyes, n = 158) without cardiac surgery in the aspirin group and 285 patients (285 eyes, n = 285) without history of antithrombotic drugs were collected. Subconjunctival hemorrhage and hyphema occurred in all three groups, but the difference was not statistically significant (P > 0.05). No other serious bleeding-related complications occurred in the three groups during the operation, 1 day and 1 week after operation.

CONCLUSION:

No matter intraoperative or postoperative, bleeding-related complications are rare in patients after PCI, which demonstrates a certain degree of surgical safety and can prove the safety of cataract surgery without stopping antithrombotic drugs.

Introduction

Whether to discontinue the antithrombotics regimen in the perioperative period of cataract is always a controversial problem. Administration of antithrombotics, such as aspirin, oral anticoagulants, antiplatelet agents, and novel oral anticoagulants before and throughout the surgical period increases the bleeding risk due to its reducing blood clot formation function, whereas, inappropriate suspension of antithrombotics administration may increase the rate of malignant cardiovascular and cerebrovascular events.[1] Aspirin, as an effective drug to inhibit platelet release and aggregation, has antithrombotic effect and has been listed as the basic drug for prevention of cardiovascular diseases in many countries.[2] However, the potential risk of bleeding caused by aspirin is often assessed in clinical practice. The influence of aspirin on blood coagulation state, especially on some small eye surgeries, is lack of clinical observation data.[3] The objective of this study is to provide some evidence by observing the bleeding risk among patients after percutaneous coronary intervention (PCI) at least 1 year continuing aspirin use in the perioperative period of cataract surgery.

Methods

(1) Retrospective analysis of the cases of cataract surgery in our hospital from February 12, 2019 to December 21, 2021, age ≥60, regardless of gender, cataract nuclear Grade IV or below, no contraindications for cataract surgery, including patients with no history of antithrombotic drugs, long-term (≥1 year) aspirin group without history of any cardiac surgery, and patients after PCI (≥1 year). Preoperative physical examination and medical history were taken to record the patient’s age, sex, cataract nuclear grade, other ocular manifestations and systemic history in detail. (2) Phacoemulsification and intraocular lens implantation were performed under topical anesthesia through clear corneal incision. All the operations were performed by two experienced doctors. Intraoperative hemorrhage-related complications were recorded, including subconjunctival hemorrhage, anterior chamber hemorrhage, vitreous hemorrhage, and choroid explosive hemorrhage. (3) A slit-lamp examination was performed 1 day after the operation to record the presence of new postoperative bleeding complications such as subconjunctival hemorrhage, anterior chamber hemorrhage, and vitreous hemorrhage. (4) A slit-lamp examination was performed 1 week after the operation to record the presence of new postoperative bleeding complications such as subconjunctival hemorrhage, anterior chamber hemorrhage, and vitreous hemorrhage.

Results

1. General information. A total of 524 patients aged 60 and over, including 524 eyes, 213 males and 311 females, were included in the study. There were 81 cases (including 35 males and 46 females) after PCI with aspirin use, 158 cases (including 73 males and 85 females) without cardiac surgery in the aspirin group, and 285 cases (including 105 males and 180 females) without history of antithrombotic drugs. The best preoperative corrected visual acuity was 0.1–0.5, and the intraocular pressure was within the normal range (10 mmHg–21 mmHg). There were no statistically significant differences in age and sex between the three groups [Table 1]

2. Aspirin Use. In this study, patients in the aspirin group without any cardiac surgery took the medicine for secondary prevention of cardiovascular diseases, including atrial fibrillation, coronary heart disease, heart valve replacement, and coronary stenting. In the PCI group, aspirin was used to reduce the risk of stent thrombosis and thereby myocardial infarction and death

3. Intraoperative bleeding-related complications. All the 524 patients had smooth operation. Intraoperative subconjunctival hemorrhagic occurred in all three groups, including 22 in no aspirin group, 9 in the aspirin group without cardiac surgery, and 6 in the PCI group, but we found no statistical difference in any comparison between each group [Table 2]. Hyphema just occurred in Percutaneous coronary intervention (PIC) group and control group, similarly, there was no significant difference between groups

4. Postoperative examination results 1 day and 1 week. No new bleeding-related complications occurred in all three groups 1 day and 1 week after the operation.

Table 1.

General information and comparison between percutaneous coronary intervention group and control group

Parameter	PCI group	No cardiac surgery group	Control group	value
Patients,	81	158	285	—
Eye,	81	158	285	—
Sex,				0.833a
Male	35	73	105
Female	46	85	180
Age, year				0.236b
Mean±SD	73.7±7.4	73.1±8.0	74.5±8.0
Range	61–87	60–96	60–94

^aChi-square test; ^bStudent’s t-test;

Table 2.

Comparison of intraoperative bleeding-related complications between percutaneous coronary intervention group and control group

Complication	PCI group (n=81)	No cardiac surgery group (n=158)	Control group (n=285)	value
Subconjunctival hemorrhagic	6 (5.7)	9 (11.2)	22 (37)	0.715a
Hyphema	1 (0.5)	0 (0.9)	2 (1.6)	0.305c

P>0.05; ^aChi-square test; ^cFisher’s exact test

Discussion

Aspirin (acetylsalicylic acid) inhibits platelet prostaglandin synthesis and the adenosine diphosphate (ADP)- and collagen-induced platelet release reaction.[4] Aspirin has an established important role in the management and prevention of thromboembolism and is used in patients with atherosclerotic, cerebrovascular, coronary artery, and peripheral arterial diseases. They are also used for secondary prevention of atrial fibrillation, ventricular arrhythmia, valvular heart diseases, hypertension, angina, myocardial infarction, and after bypass surgery.[5] However, as well as reducing clots, aspirin also increases the risk of bleeding.[6] A retrospective cohort study of low-dose aspirin using in Japan found a 3.9% incidence of gastrointestinal bleeding in patients with cardiovascular disease.[7] The incidence of total gastrointestinal bleeding after PCI within 30 days was 4.3%.[8] In addition, the effect of long-term aspirin on intraoperative bleeding is also a research hotspot. Some studies have shown that some patients with oral aspirin often have intraoperative bleeding during elective surgeries in the general surgery department.[9] At the same time, a meta-analysis of more than 50,000 patients receiving aspirin for secondary prevention demonstrated that stopping aspirin increased the risk of major cardiovascular events three-fold,[10] and some patients even have aspirin resistance when they resume the medication.[11] Therefore, the clinical evidence of intraoperative bleeding effect in patients with oral aspirin can effectively guide clinical work.

According to the World Health Organization, cataract surgery is the most frequently performed surgical procedure in the world.[12] Phacoemulsification combined with intraocular lens implantation under clear corneal incision is one of the most common operations in ophthalmology.[13] Studies have shown that 28.1% of cataract patients take aspirin for a long time.[14] In clinical work, low molecular weight heparin is sometimes used in patients with oral aspirin. However, withdrawal or reduction without authorization will increase the incidence of cardiovascular and cerebrovascular malignant events.[15] In this regard, relevant studies have found that invasive anesthesia in ophthalmic surgery will increase the risk of bleeding, including retrobulbar anesthesia, tenon capsule anesthesia.[16] However, for noncomplex cataract surgery, topical anesthesia can be used, i.e. needle independent. Previous studies have shown that this anesthesia reduces the risk of surgical bleeding.[3,17,18] Clear corneal incision avoids the blood vessels on the surface of conjunctiva and sclera, and reduces the risk of bleeding.[14] In some guidelines, anterior chamber surgeries, including cataracts, are considered low risk.[19] Previous studies have indicated that phacoemulsification cataract surgery under topical anesthesia could be safely performed without ceasing systemic aspirin therapy.[20,21,22] However, there is little evidence for the safety of long-term aspirin use after cardiac surgery. Patients after some kinds of cardiac surgeries may receive a single antithrombotic agent or a combination, and the duration of therapy may vary from months to years. To reduce the risk of stent thrombosis and thereby myocardial infarction and death, double platelet inhibition (aspirin and ADP receptor antagonists such as clopidogrel, prasugrel or ticagrelor) is the recommended treatment in the 1^st year after PCI.[23] Aspirin is usually taken regularly from the 2^nd year after the surgery. The patients after PCI can take medicine regularly, and can be reexamined in outpatient department on time. They have good medical compliance and follow-up rate.

In this study, we selected patients who took aspirin for at least 1 year after PCI, and performed phacoemulsification combined with intraocular lens implantation through clear corneal incision under topical anesthesia, and evaluated the impact of aspirin on bleeding and the safety of surgery.

A total of 524 patients were included in this study. Eighty-one patients had a history of taking aspirin after PCI, 158 patients had taken aspirin for secondary prevention, and 285 patients had no history of antithrombotic drugs. No matter intraoperative or postoperative, bleeding-related complications are rare, with a certain degree of surgical safety.

Conclusion

Long-term aspirin use in patients undergoing minimally invasive surgery for noncomplex cataracts results in few bleeding-related complications and is of certain safety.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.