Ophthalmic Surgery in Cirrhosis

Chapter

Abstract

When planning an eye surgery for patients with cirrhosis, as with any surgical intervention, it is important to assess their propensity for abnormal bleeding. This factor must be taken into consideration for both anesthesia as well as the selection of the surgical technique. In cases with a hypocoagulopathy, less invasive anesthesia techniques, including topical with or without intracameral, subconjunctival, and sub-Tenon injections, are safer choices. Whenever possible, it is best to avoid the use of a standard retrobulbar injection due to the risk of blindness from a retrobulbar hemorrhage.

Modern cataract surgery with the phacoemulsification technique and insertion of a foldable intraocular lens (IOL) is typically performed through an avascular corneal incision, under topical anesthesia, without any risk of bleeding. Bleeding has become less of an issue with vitreoretinal procedures as the scleral incisions are now much smaller. There is a greater concern when performing oculoplastic procedures on the highly vascularized eyelids.

The other major factor of importance is to assess the cirrhotic patient for the ability to lie comfortably in a supine position for the extent of the entire operation. It is also important for the ophthalmic surgeon to be aware of potential tear-film deficiencies in these patients, as a significant number are at greater risk for postoperative ocular surface disorders.

Keywords

Cataract surgery Vitrectomy Choroidal hemorrhage Retrobulbar hemorrhage Ophthalmic anesthesia Dry eye syndrome 

References

  1. 1.
    Nemiroff J, Baharestani S, Juthani VV, Klein KS, Zoumalan C. Cirrhosis-related coagulopathy resulting in disseminated intravascular coagulation and spontaneous orbital hemorrhages. Orbit. 2014;33(5):372–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Sirkanth K, Kumar MA. Spontaneous expulsive suprachoroidal hemorrhage caused by decompensated liver disease. Indian J Ophthalmol. 2013;61920:78–9.CrossRefGoogle Scholar
  3. 3.
    Leaming DV. Practice styles and preferences of ASCRS members: 2003 survey. J Cataract Refract Surg. 2004;30:892–900.CrossRefPubMedGoogle Scholar
  4. 4.
    El-Hindy N, Johnston RL, Jaycock P, et al. The Cataract National Dataset Electronic Multicentre Audit of 55 567 operations: anesthetic techniques and complications. Eye. 2009;23:50–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Virtanen P, Huha T. Pain in scleral pocket incision cataract surgery using topical and peribulbar anesthesia. J Cataract Refract Surg. 1998;24:1609–13.CrossRefPubMedGoogle Scholar
  6. 6.
    Petersen WC, Yanoff M. Subconjunctival anesthesia: an alternative to retrobulbar and peribulbar techniques. Ophthalmic Surg. 1991;22:199–201.PubMedGoogle Scholar
  7. 7.
    Vicary D, McLennan S, Sun XY. Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up. J Cataract Refract Surg. 1998;24:1247–51.CrossRefPubMedGoogle Scholar
  8. 8.
    Guise PA. Sub-Tenon anesthesia: a prospective study of 6,000 blocks. Anesthesiology. 2003;98:964–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Kershner RM. Topical anesthesia for small incision self-sealing cataract surgery. A prospective evaluation of the first 100 patients. J Cataract Refract Surg. 1993;19:290–2.CrossRefPubMedGoogle Scholar
  10. 10.
    Yepez J, Cedeno de Yepez J, Arevalo JF. Topical anesthesia for phacoemulsification, intraocular lens implantation, and posterior vitrectomy. J Cataract Refract Surg. 1999;25:1161–4.CrossRefPubMedGoogle Scholar
  11. 11.
    Yepez J, Cedeno de Yepez J, Arevalo JF. Topical anesthesia in posterior vitrectomy. Retina. 2000;20:41–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Karp CL, Cox TA, Wagoner MD, et al. Intracameral anesthesia: a report by the American Academy of Ophthalmology. Ophthalmology. 2001;108:1704–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Stupp T, Hassouna I, Soppart K, et al. Systemic adverse events: a comparison between topical and peribulbar anaesthesia in cataract surgery. Ophthalmologica. 2007;221:320–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Holloway KB. Control of the eye during general anaesthesia for intraocular surgery. Br J Anaesth. 1980;52:671–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Ling R, Cole M, James C, et al. Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes. Br J Ophthalmol. 2004;88:478–80.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Nouvellon E, Cuvillon P, Ripart J. Regional anesthesia and eye surgery. Anesthesiology. 2010;113:1236–42.CrossRefPubMedGoogle Scholar
  17. 17.
    Ling R, Kamalarajah S, Cole M, et al. Suprachoroidal haemorrhage complicating cataract surgery in the UK: a case control study of risk factors. Br J Ophthalmol. 2004;88:474–7.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Barequet IS, Sachs D, Shenkman B, et al. Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg. 2011;37:1434–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Grzybowski A, Ascaso FJ, Kupidura-Majewski K, Packer M. Continuation of anticoagulant and antiplatelet therapy during phacoemulsification cataract surgery. Curr Opin Ophthalmol. 2015;26:28–33.CrossRefPubMedGoogle Scholar
  20. 20.
    Eriksson A, Koranyi G, Seregard S, Philipson B. Risk of acute suprachoroidal hemorrhage with phacoemulsification. J Cataract Refract Surg. 1998;24:793–800.CrossRefPubMedGoogle Scholar
  21. 21.
    Katz J, Feldman MA, Bass EB, et al. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology. 2003;110:1784–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Kobayashi H. Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract surgery. J Cataract Refract Surg. 2010;36:1115–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Kumar N, Jivan S, Thomas P, McLure H. Sub-Tenon’s anesthesia with aspirin, warfarin, and clopidogrel. J Cataract Refract Surg. 2006;32:1022–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Bonhomme F, Hafezi F, Boehlen F, Habre W. Management of antithrombotic therapies in patients scheduled for eye surgery. Eur J Anesthesiol. 2013;30:449–54.CrossRefGoogle Scholar
  25. 25.
    Barequet IS, Sachs D, Priel A, et al. Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment. Am J Ophthalmol. 2007;144:719–23.CrossRefPubMedGoogle Scholar
  26. 26.
    McCormack C, Simcock P, Tullo A. Management of the anticoagulated patient for ophthalmic surgery. Eye. 1993;7:749–50.CrossRefPubMedGoogle Scholar
  27. 27.
    Gainey SP, Robertson DM, Fay W, Ilstrup D. Ocular surgery on patients receiving long-term warfarin therapy. Am J Ophthalmol. 1989;108:142–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Dayani PN, Grand MG. Maintenance of warfarin anticoagulation for patients undergoing vitreoretinal surgery. Arch Ophthalmol. 2006;124:1558–65.CrossRefPubMedGoogle Scholar
  29. 29.
    Fu AD, McDonald HR, Williams DF, et al. Anticoagulation with warfarin in vitreoretinal surgery. Retina. 2007;27:290–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Chandra A, Jazayeri F, Williamson TH. Warfarin in vitreoretinal surgery: a case controlled series. Br J Ophthalmol. 2011;95:976–8.CrossRefPubMedGoogle Scholar
  31. 31.
    McMahan L. Anticoagulants and cataract surgery. J Cataract Refract Surg. 1988;14:569–70.CrossRefPubMedGoogle Scholar
  32. 32.
    Tabandeh H, Sullivan PM, Smahliuk P, et al. Suprachoroidal hemorrhage during pars plana vitrectomy. Risk factors and outcomes. Ophthalmology. 1999;106:236–42.CrossRefPubMedGoogle Scholar
  33. 33.
    Oh J, Smiddy WE, Kim SS. Antiplatelet and anticoagulation therapy in vitreoretinal surgery. Am J Ophthalmol. 2011;151:934–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Brown JS, Mahmoud TH. Anticoagulation and clinically significant postoperative vitreous hemorrhage in diabetic vitrectomy. Retina. 2011;31:1983–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Malik AI, Foster RE, Correa ZM, Peterson MR, Miller DM, et al. Anatomical and visual results of transconjunctival sutureless vitrectomy using sobconjunctival anesthesia performed on select patients taking anticoagulant and antiplatelet agents. Retina. 2012;32:905–11.CrossRefPubMedGoogle Scholar
  36. 36.
    Rosenfeld PJ, Brown DM, Heier JS, MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355:1419–31.CrossRefPubMedGoogle Scholar
  37. 37.
    Brown DM, Kaiser PK, Michels M, ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. 2006;355:1432–44.CrossRefPubMedGoogle Scholar
  38. 38.
    Cobb CJ, Chakrabarti S, Chadha V, Sanders R. The effect of aspirin and warfarin therapy in trabeculectomy. Eye. 2007;21:598–603.PubMedGoogle Scholar
  39. 39.
    Law SK, Song BJ, Yu F, et al. Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy. Am J Ophthalmol. 2008;145:736–46.CrossRefPubMedGoogle Scholar
  40. 40.
    Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of post blepharoplasty orbital hemorrhage and associated visual loss. Ophthal Plast Reconstr Surg. 2004;20:426–32.CrossRefPubMedGoogle Scholar
  41. 41.
    Custer PL, Trinkaus KM. Hemorrhagic complications of oculoplastic surgery. Ophthal Plast Reconstr Surg. 2002;18:409–15.CrossRefPubMedGoogle Scholar
  42. 42.
    Bartley GB, Nichols WL. Hemorrhage associated with dacryocystorhinostomy and the adjunctive use of desmopressin in selected patients. Ophthalmology. 1991;98:1864–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Kedhar SR, Belair ML, Jun AS, et al. Scleritis and peripheral ulcerative keratitis with hepatitis C virus-related cryoglobulinemia. Arch Ophthalmol. 2007;125:852–3.CrossRefPubMedGoogle Scholar
  44. 44.
    Jacobi C, Wenkel H, Jacobi A, et al. Hepatitis C and ocular surface disease. Am J Ophthalmol. 2007;144:705–11.CrossRefPubMedGoogle Scholar
  45. 45.
    Giovannini A, Ballardini G, Amatetti S, Bonazzoli P, Bianchi FB. Patterns of lacrimal dysfunction in primary biliary cirrhosis. Br J Ophthalmol. 1985;69:832–5.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Gumus K, Yurci A, Mirza E, et al. Evaluation of ocular surface damage and dry eye status in chronic hepatitis C at different stages of hepatic fibrosis. Cornea. 2009;28:997–1002.CrossRefPubMedGoogle Scholar
  47. 47.
    Haddad J, Deny P, Munz-Gotheil C, et al. Lymphocytic sialadenitis of Sjogren’s syndrome associated with chronic hepatitis C virus liver disease. Lancet. 1992;339:321–3.CrossRefPubMedGoogle Scholar
  48. 48.
    Huang FC, Shih MH, Tseng SH, et al. Tear function changes during interferon and ribavirin treatment in patients with chronic hepatitis C. Cornea. 2005;24:561–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007;26(9 Suppl 1):S16–20.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.The Retina Service, Department of OphthalmologyUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.The Retina Service, UPMC Eye Center, Department of OphthalmologyUniversity of Pittsburgh School of Medicine, The Eye and Ear InstitutePittsburghUSA

Personalised recommendations