SMALL INCISION MANUAL ECCE (BLUMENTHAL TECHNIQUE) IN PATIENTS ON WARFARIN THERAPY

1. SMALL INCISION MANUAL ECCE (BLUMENTHAL TECHNIQUE) IN PATIENTS ON WARFARIN THERAPY Yossi Yatziv M.D., Moshe Lazar M.D. Tel Aviv Medical Center

2. Background • The use of Warfarin in the elderly population undergoing cataract surgery is not uncommon • A recent survey done in the U.K. found that 5.1% of patients undergoing cataract surgery were taking Wafarin at the time of surgery1. • Despite the wide use of oral anticoagulants in candidates for cataract surgery the is no consensus addressing the issue of whether to continue these medications during surgery.

3. Background • Phacoemulsification is, by far the most widely used technique for cataract extraction in developed countries. • Due to the costly machinery and consumables manual ECCE is increasingly employed in developing countries and has shown to yield similarsurgical outcomes2. • In a modern environment, due to the surgeons’ preference or surgical considerations, a considerable percentage of cataract extractions are done using the manual technique.

4. Background • Several studies documented the safety of phacoemulsification cataract surgery in patients on Warfarin therapy3-5. • A few earlier reports examined the hemorrhagic complications in patients undergoing manual ECCE cataract surgery4,6-8. they reported only minor complications. • Some of these studies compared the rate of hemorrhagic complications between the manual and phaco techniques. They concluded that phacoemulsification should be the preferred technique when performing cataract surgery on patient receiving Warfarin4,8.

5. Purpose • The purpose of our study is to examine the rate of hemorrhagic complications in patients under Warfarin therapy undergoing cataract surgery using the small incision manual ECCE (Blumenthal technique)

6. Methods • We retrospectively examined the files of 21 non-selected patients who underwent cataract surgery between the years 2004-2007 using the small incision manual ECCE technique while on uninterrupted Warfarin (Coumadin, Taro, Israel) therapy. • Patient files were reviewed and data regarding the patient systemic illnesses and indication for Warfarin therapy was recorded.

7. Methods • All patients underwent complete ophthalmologic and systemic examination. • Patients were instructed to continue taking all their medications, including Warfarin as usual. • The prothrombine time before surgery was determined using the international normalized ratio (INR). • Patients with an INR above 3.0 were excluded from the study.

8. Methods • All surgeries were performed by a single surgeon (M.L.) using the small incision manual ECCE technique. • All cases were done under subtenon anesthesia with 2% Lidocaine. • The surgical technique included an anterior chamber maintainer and expression of the nucleus through a 4-5mm scleral tunnel. An non foldable PMMA lens was implanted. • Records of any intraoperative complications were recorded in the postoperative report. • Patients were examined 1,7 and 30 days postoperatively and any late complications were noted.

9. Results • The mean age of 8 men and 13 women was 72 years. • The indications for anticoagulant therapy was chronic atrial fibrillation (12 patients), artificial valves (6 patients), cardiomyopathy (2 patients) and deep vein thrombosis (1 patient) • The mean INR before surgery was 2.1 (±0.5)

10. Results • There were no instances of significant bleeding during or after surgery. • 11 patients had postoperative subconjunctival hemorrhage which resolved spontaneously. • The postoperative visual outcome was favorable with 82% of the patients achieving visual acuity of 20/40 or better at 30 days.

11. Conclusions • This study demonstrates that cataract surgery in nonselected patients receiving Warfarin therapy (with an INR<3.0) can be safely performed using the small incision manual technique (Blumenthal technique). In memory of Professor Michael Blumenthal (1935-2007)

12. Bibliography • Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AK, Eke T, Sparrow JM. The Cataract National Dataset electronic multicentre audit of 55 567 operations: antiplatelet and anticoagulant medications. Eye. 2008 Feb 8 [Epub ahead of print] • Tabin G, Chen M, Espandar L. Cataract surgery for the developing world. Curr Opin Ophthalmol. 2008;19(1):55-9 • Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, Fleisher LA, Schein OD; Study of Medical Testing for Cataract Surgery Team. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology. 2003;110(9):1784-8. • Rotenstreich Y, Rubowitz A, Segev F, Jaeger-Roshu S, Assia EI. Effect of warfarin therapy on bleeding during cataract surgery. J Cataract Refract Surg. 2001 Sep;27(9):1344-6. • Barequet IS, Sachs D, Priel A, Wasserzug Y, Martinowitz U, Moisseiev J, Salomon O. Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment. Am J Ophthalmol. 2007 Nov;144(5):719-723. Epub 2007 Sep 17. • McMahan LB. Anticoagulants and cataract surgery. J Cataract Refract Surg. 1988;14(5):569-71. • Robinson GA, Nylander A. Warfarin and cataract extraction. Br J Ophthalmol. 1989;73(9):702-3. • Saitoh AK, Saitoh A, Taniguchi H, Amemiya T. Anticoagulation therapy and ocular surgery. Ophthalmic Surg Lasers. 1998;29(11):909-15.