Risk Management

Coumadin and Ocular Anesthesia

By Paul Weber, JD

Digest, Spring 1998

Recently, I took an incident report from an insured who stopped a patient’s Coumadin five days prior to surgery. Two days after surgery, the patient suffered a devastating stroke. The specific risks of discontinuing Coumadin were not discussed with this patient prior to surgery. It was the first time an incident of this kind was reported to OMIC, although the question of whether to stop Coumadin prior to cataract (or intraocular) surgery has come up a number of times. Quite often, an important risk management issue such as this one will raise both clinical and legal issues. When this occurs, we are fortunate to be able to collaborate on the clinical issues with ophthalmologists from OMIC’s Board and Committees.

In this case, Risk Management Committee Chairman Dean C. Brick, MD, a cornea specialist in Tucson, addressed the prevalent clinical issues. We realize this is a controversial topic and would appreciate hearing from our readers on this one.

Q  Should I discontinue a patient’s Coumadin prior to cataract (or intraocular) surgery?
A  This is a difficult situation since Coumadin puts both patient and surgeon at increased risk. If you continue the patient on Coumadin, you risk being sued if the patient develops bleeding problems. If you discontinue the Coumadin and the patient suffers a stroke, you may be sued for not advising the patient of the risks involved in stopping the medication. Two critical decisions must be made in these patients.

The first is whether the patient needs to be maintained on full doses of Coumadin prior to and during surgery. In many cases, patients are on Coumadin for prophylactic reasons and may safely discontinue it for a few days prior to surgery to allow the INR to decrease but not to a normal level. This option should be discussed with the primary care physician monitoring the patient’s anticoagulant and the discussion and decision reviewed with the patient and documented in the chart. If the decision to stop Coumadin is made, routine technique and anesthesia (including retrobulbar anesthesia) are appropriate.

Q  What surgical technique or anesthesia should I use in patients whose anticoagulant cannot be discontinued or decreased such as those with artificial heart valves?
A  This leads to the second critical decision: Should you change your technique of surgery or anesthesia? If a patient’s INR remains significantly elevated prior to surgery, the patient faces the risk of retrobulbar hemorrhage following retrobulbar or peribulbar anesthesia as well as the possibility of a more severe suprachoroidal hemorrhage. It might seem that topical anesthesia would be the technique of choice in these cases; however, OMIC has had two cases of suprachoroidal hemorrhage associated with topical anesthesia in which the patients complained of pain during surgery. It was alleged that the patient’s pain and discomfort resulted in elevated blood pressure and hemorrhage. Even though there are still risks of complications, topical anesthesia is probably the technique of choice for such patients provided the physician and anesthetist are experienced with its application.

If not, the surgeon should refer the patient to a surgeon who is experienced with this technique or modify his or her technique to fit the circumstances.

Q  If after weighing the options, it is decided that injectable anesthesia is the technique to use on a patient, how can I minimize the risk of complications?
A  Use a Greenbaum cannula or blunted needle to administer the anesthetic. A prolonged massage following the injection will prevent the formation of a large hemorrhage, which would compromise circulation to the globe or optic nerve. Closely observe the patient for signs of hemorrhage prior to, during and after surgery. Provide instructions before the patient leaves the hospital on how to recognize the signs of hemorrhage and how to contact you if any of these symptoms occur. Always be prepared to respond to emergencies. There are health risks to the patient and concomitant liability risks to the surgeon with any decision in situations like this. Discuss all the options and risks with the patient and document the reasons for the final decision in the chart.