PostScript
Authors’ response We thank Grzybowski et al for their comments on our paper.1 The main contention of the authors is that patients undergoing cataract surgery with
1136
antiplatelet (Ap) and/or anticoagulant (Ac) medications should continue to receive these drugs based on evidence in the medical literature. In our paper, we clearly acknowledge that the predominant technique for lens extraction is phacoemulsification, and that the risk of complications related to bleeding is rare. In one of the papers2 referenced by Grzybowski et al, a small, but not insignificant, risk of intraoperative haemorrhage in patients undergoing cataract surgery is mentioned, with no reported effect on visual outcome. The meta-analysis did not, however, specifically review patients with a target international normalised ratio (INR) of over 3 or those on dual therapy (ie, warfarin and aspirin). Benzimra et al3 conducted a large retrospective study using electronic patient records and once again found that there was no increased risk of sight-threatening complications related to the administration of local anaesthetic or cataract surgery itself, in patients who were recorded as previously taking Ap/Ac therapy. This paper did not review whether such therapy had been discontinued or modified prior to cataract surgery which could result in under-reporting of complications. Moreover, there was no mention made of the clinical indication for Ap/Ac therapy or a target INR in patients taking warfarin which has relevance. Clearly there is a paucity of evidence on which to base practice for every possible situation, particularly for patients on novel therapies such as Apixiban and Dabigatran. We have outlined a risk stratification strategy to take into consideration an assortment of clinical scenarios. In our opinion, adopting a ‘one size fits all approach’ is inadvisable for patients on Ap/Ac therapy and we would recommend an individualised approach. For example, a patient with only one eye and a metallic heart valve on dual Ap/Ac therapy with a target INR of 3.5 will require a more judicious approach than a patient on single agent therapy for primary prevention. In conclusion, we would agree that continuation of antiplatelet and/or anticoagulant medications in the vast majority of patients undergoing cataract surgery is the correct approach. We would also advise that the clinician has a rudimentary knowledge of such therapy and is, therefore, able to pre-empt and manage situations where the potential risks to life or vision is increased. Rajarshi Mukherjee,1 Christine A Kiire,1 Neil Ruparelia,2 David Keeling,3 Bernard Prendergast,2 Jonathan H Norris1
Br J Ophthalmol August 2014 Vol 98 No 8
PostScript 1
Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK 2 Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK 3 Department of Haematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK Correspondence to Jonathan H Norris, Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; [email protected] Contributors RM and CAK contributed to the design of the manuscript, acquisition of the data, drafting of the work and approval of the final manuscript. NR and BP contributed to the antiplatelet section including the design, drafting and final approval. DK contributed to the anticoagulant section including the design, drafting and final approval. JHN was the overall in-charge of the work. He conceptualised the project, contributed to the design and drafting of the work and was responsible for final approval of the whole of the manuscript. He is the corresponding author for this article. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Mukherjee R, Kiire CA, Ruparelia N, et al. Br J Ophthalmol 2014;98:1136–1137. Received 12 May 2014 Accepted 13 May 2014 Published Online First 29 May 2014
▸ http://dx.doi.org/10.1136/bjophthalmol-2014305411 Br J Ophthalmol 2014;98:1136–1137. doi:10.1136/bjophthalmol-2014-305527
REFERENCES 1
2
3
Kiire CA, Mukherjee R, Ruparelia N, et al. Managing antiplatelet and anticoagulant drugs in patients undergoing elective ophthalmic surgery. Br J Ophthalmol Published Online First: 1 April 2014. doi:10.1136/bjophthalmol-2014-304902 Jamula E, Anderson J, Douketis JD. Safety of continuing warfarin therapy during cataract surgery: a systematic review and meta-analysis. Thromb Res 2009;124:292–9. Benzimra JD, Johnston RL, Jaycock P, et al. EPR User Group. The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications. Eye 2009;23:10–16.
Br J Ophthalmol August 2014 Vol 98 No 8
1137
Copyright of British Journal of Ophthalmology is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Authors’ response We thank Grzybowski et al for their comments on our paper.1 The main contention of the authors is that patients undergoing cataract surgery with
1136
antiplatelet (Ap) and/or anticoagulant (Ac) medications should continue to receive these drugs based on evidence in the medical literature. In our paper, we clearly acknowledge that the predominant technique for lens extraction is phacoemulsification, and that the risk of complications related to bleeding is rare. In one of the papers2 referenced by Grzybowski et al, a small, but not insignificant, risk of intraoperative haemorrhage in patients undergoing cataract surgery is mentioned, with no reported effect on visual outcome. The meta-analysis did not, however, specifically review patients with a target international normalised ratio (INR) of over 3 or those on dual therapy (ie, warfarin and aspirin). Benzimra et al3 conducted a large retrospective study using electronic patient records and once again found that there was no increased risk of sight-threatening complications related to the administration of local anaesthetic or cataract surgery itself, in patients who were recorded as previously taking Ap/Ac therapy. This paper did not review whether such therapy had been discontinued or modified prior to cataract surgery which could result in under-reporting of complications. Moreover, there was no mention made of the clinical indication for Ap/Ac therapy or a target INR in patients taking warfarin which has relevance. Clearly there is a paucity of evidence on which to base practice for every possible situation, particularly for patients on novel therapies such as Apixiban and Dabigatran. We have outlined a risk stratification strategy to take into consideration an assortment of clinical scenarios. In our opinion, adopting a ‘one size fits all approach’ is inadvisable for patients on Ap/Ac therapy and we would recommend an individualised approach. For example, a patient with only one eye and a metallic heart valve on dual Ap/Ac therapy with a target INR of 3.5 will require a more judicious approach than a patient on single agent therapy for primary prevention. In conclusion, we would agree that continuation of antiplatelet and/or anticoagulant medications in the vast majority of patients undergoing cataract surgery is the correct approach. We would also advise that the clinician has a rudimentary knowledge of such therapy and is, therefore, able to pre-empt and manage situations where the potential risks to life or vision is increased. Rajarshi Mukherjee,1 Christine A Kiire,1 Neil Ruparelia,2 David Keeling,3 Bernard Prendergast,2 Jonathan H Norris1
Br J Ophthalmol August 2014 Vol 98 No 8
PostScript 1
Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK 2 Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK 3 Department of Haematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK Correspondence to Jonathan H Norris, Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; [email protected] Contributors RM and CAK contributed to the design of the manuscript, acquisition of the data, drafting of the work and approval of the final manuscript. NR and BP contributed to the antiplatelet section including the design, drafting and final approval. DK contributed to the anticoagulant section including the design, drafting and final approval. JHN was the overall in-charge of the work. He conceptualised the project, contributed to the design and drafting of the work and was responsible for final approval of the whole of the manuscript. He is the corresponding author for this article. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Mukherjee R, Kiire CA, Ruparelia N, et al. Br J Ophthalmol 2014;98:1136–1137. Received 12 May 2014 Accepted 13 May 2014 Published Online First 29 May 2014
▸ http://dx.doi.org/10.1136/bjophthalmol-2014305411 Br J Ophthalmol 2014;98:1136–1137. doi:10.1136/bjophthalmol-2014-305527
REFERENCES 1
2
3
Kiire CA, Mukherjee R, Ruparelia N, et al. Managing antiplatelet and anticoagulant drugs in patients undergoing elective ophthalmic surgery. Br J Ophthalmol Published Online First: 1 April 2014. doi:10.1136/bjophthalmol-2014-304902 Jamula E, Anderson J, Douketis JD. Safety of continuing warfarin therapy during cataract surgery: a systematic review and meta-analysis. Thromb Res 2009;124:292–9. Benzimra JD, Johnston RL, Jaycock P, et al. EPR User Group. The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications. Eye 2009;23:10–16.
Br J Ophthalmol August 2014 Vol 98 No 8
1137
Copyright of British Journal of Ophthalmology is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
