Editorial
Anticoagulants and vitreoretinal surgery
Anticoagulantes y cirugía vitreorretiniana
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Andonegui, A. Zubicoa" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Andonegui" "email" => array:1 [ 0 => "jandonen@cfnavarra.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Zubicoa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Red Temática de Investigación Cooperativa en Oftalmología RD 12/0034 «Oftalred»" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anticoagulantes y cirugía vitreorretiniana" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">When a patient in treatment with oral anticoagulants is scheduled for vitreoretinal surgery, the retinologist has 2 options, the first being the interruption of anticoagulant therapy, assuming the systemic thromboembolic risks this implies. The other option is to maintain anticoagulation, face possible intra-and postoperative hemorrhagic complications that could emerge when operating in these conditions. Even though it is conventionally considered that it is necessary to interrupt anticoagulants before this type of surgery, recently some authors have questioned this approach, consider that hemorrhagic risks associated to maintaining said therapy are minimally relevant and, in addition, by maintaining the treatment the possibility of systemic thromboembolic complications is minimized. Suspending anticoagulant therapy, applying substitution therapy is also complicated for the patient who must substitute a therapeutic routine by a new and unfamiliar routine. In addition, this change involves delaying surgery for a few days, which could be a serious drawback and significantly compromise postoperative visual recovery in some urgent surgery indications such as retina detachment with adaptive macula or endophthalmitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The use of oral anticoagulant medication to diminish thromboembolic occurrences is widespread in our country, above all for elderly patients. The most utilized anticoagulants are vitamin K antagonist such as acenocumarol or new oral direct action anticoagulants, which include dabigatran, rivaroxaban, apixaban and edoxaban. The most frequent indication for the administration of these drugs is auricular fibrillation, although they are also prescribed for artificial cardiac valves, ischemic cardiopathy, deep venous thrombosis,hypercoagulability and peripheral vasculopathies. The indications for these new anticoagulants continue to increase and it is expected that the number of patients in treatment with these drugs will continue to increase in the next few years. In addition, the amount and indications for vitreoretinal surgery had grown in recent years, and it can be expected that this trend will continue in the future.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The vast majority of studies evaluating the risks of maintaining anticoagulant treatments during intraocular surgery have been conducted with patients operated for cataracts,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> but very few studies have been made on retina surgery patients. Most authors agree in that maintaining anticoagulant therapy in patients scheduled for retinal surgery does not significantly increase the risk of hemorrhagic events during or after surgery.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Even though some authors describe slight increases in the risk of hemorrhagic complications in patients with anticoagulants who underwent vitrectomy, in general the incidence is very low and have not shown statistical significance in addition to the absence of severe consequences for long-term visual recovery.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> It must be pointed out that all of said studies have the limitation of being of a retrospective and nonrandomized nature.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand, halting anticoagulant therapy prior to surgery is not free of risks as it could increase the incidence of thromboembolic events. Some authors have suggested that the interruption of anticoagulant treatment could give rise to a significant surge of hypercoagulability and described cases of severe and even fatal complications after suspending said treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At present there is no clear consensus on the necessity of interrupting oral anticoagulant therapy prior to vitreoretinal surgery. In contrast with the rest of ocular surgeries, vitreoretinal surgery has been classified as high hemorrhagic risk, which means that any perioperative bleeding could have a very severe consequences for the patient. We believe that this approach is not consistently supported by the information available at present and, as described above, hemorrhagic complications that these patients could develop have very low clinic transcendence. In general, they resolve spontaneously without leaving long-term sequels. However, systemic thromboembolic risk is comparatively higher with the interruption of anticoagulant therapy. For this reason, in recent years some authors are proposing a modification of the approach and classifying vitreoretinal surgery as having moderate or even low risk, thus enabling the consummation of anticoagulant treatment prior to surgery.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> In a recent study comprising 167 members of the British Association of Vitreoretinal Surgeons, 79 stated they continued treatment with warfarin, while 58% continued treatment with new oral anticoagulants prior to surgery.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Even though to date we do not have the results of prospective and randomized studies that can demonstrate this approach, we consider that current scientific evidence indicates that maintaining anticoagulant therapy during vitreoretinal surgery is a safe option for the patient from the ocular as well as the systemic viewpoint. This approach involves several developments, specially eliminating systemic risks due to the interruption of anticoagulant treatment prior to surgery. However, it also does away with the drawbacks derived from establishing substitution therapy and above all the surgery can be carried out without delays, with the benefits this brings in urgent surgery indications. In any case, this new paradigm should be confirmed in the future by means of adequately designed studies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Andonegui J, Zubicoa A. Anticoagulantes y cirugía vitreorretiniana. Arch Soc Esp Oftalmol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.04.004">https://doi.org/10.1016/j.oftal.2020.04.004</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Katz" 1 => "M.A. Feldman" 2 => "E.B. Bass" 3 => "L.H. Lubomski" 4 => "J.M. Tielsch" 5 => "B.G. Petty" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0161-6420(03)00785-110.1016/S0161-6420(03)00785-1" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology." 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