Department of Ophthalmology, University Medical Center Goettingen, Robert-Koch-Str, 40 37075, Goettingen, Germany.
Department of Radiology, St. Franziskus Hospital, Muenster, Hohenzollernring 70, 48145, Münster, Germany.
Graefes Arch Clin Exp Ophthalmol. 2020 May;258(5):961-969. doi: 10.1007/s00417-019-04554-1. Epub 2020 Jan 7.
The goal of this study was to analyze the incidence of perioperative bleeding complications in rhegmatogenous retinal detachment. The handling of perioperative anticoagulation during vitreoretinal surgery remains controversial, since the risk of bleeding complications by its continuation has to be balanced against the risk of progression of retinal detachment and the risk of thromboembolic events when anticoagulation is interrupted. Nevertheless, only few studies have investigated the risk of perioperative bleeding complications in an emergency such as retinal detachment surgery.
We therefore examined the rate of all perioperative hemorrhages and separately the rate of only severe bleedings during vitrectomy, scleral buckling with or without drainage of subretinal fluid (SRD), or combined procedures due to retinal detachment in patients undergoing different types of perioperative anticoagulation including acetylsalicylic acetate (ASA), clopidogrel, heparin, low molecular weight heparin, and phenprocoumon.
This retrospective single-center study included 893 patients with primary rhegmatogenous retinal detachment, n = 192 on anticoagulation and n = 701 serving as control without anticoagulation. Our analysis revealed no significantly increased rate of perioperative hemorrhages under anticoagulation with ASA 100 mg (all, 11.4%; severe, 5.0%) or phenprocoumon (all, 11.6%; severe, 2.3%) compared with controls (all, 13.0%; severe, 5.4%). However, frequencies of bleeding complications varied markedly regarding the type of surgical procedure: Scleral buckling plus SRD showed the highest rates of hemorrhages (all, 18.9%; severe, 9.1%) with significant difference (P < 0.001) compared with scleral buckling without SRD (all, 3.8%; severe, 0.6%) and vitrectomy (all, 9.2%; severe, 1.5%), respectively. Furthermore, subretinal bleeding was the most common type of perioperative hemorrhage.
The data suggest not to stop ASA therapy prior to vitreoretinal surgery. Furthermore, we found no evidence of an increased risk for perioperative bleedings in patients under anticoagulation with vitamin-k antagonists with an INR within the sub-therapeutic range. SRD during scleral buckling procedure should be avoided as possible and regardless of any type of anticoagulation.
本研究旨在分析孔源性视网膜脱离患者围手术期出血并发症的发生率。玻璃视网膜手术期间抗凝处理仍存在争议，因为继续抗凝的出血并发症风险需要与视网膜脱离进展的风险以及中断抗凝时血栓栓塞事件的风险相平衡。然而，只有少数研究调查了视网膜脱离手术等紧急情况下围手术期出血并发症的风险。
因此，我们检查了所有围手术期出血的发生率，以及单独检查了玻璃体切割术、巩膜扣带术伴或不伴视网膜下液引流（SRD）或联合手术期间仅严重出血的发生率，这些患者接受了不同类型的围手术期抗凝治疗，包括乙酰水杨酸（ASA）、氯吡格雷、肝素、低分子肝素和苯丙香豆素。
这项回顾性单中心研究纳入了 893 例原发性孔源性视网膜脱离患者，其中 192 例接受抗凝治疗，701 例作为无抗凝治疗的对照组。我们的分析显示，ASA 100mg（所有，11.4%；严重，5.0%）或苯丙香豆素（所有，11.6%；严重，2.3%）抗凝治疗的患者围手术期出血发生率无显著增加，与对照组（所有，13.0%；严重，5.4%）相比。然而，出血并发症的频率因手术类型而异：巩膜扣带术加 SRD 显示出血发生率最高（所有，18.9%；严重，9.1%），与巩膜扣带术不加 SRD（所有，3.8%；严重，0.6%）和玻璃体切割术（所有，9.2%；严重，1.5%）相比有显著差异（P<0.001）。此外，视网膜下出血是围手术期最常见的出血类型。
数据表明，在玻璃体视网膜手术前不应停止 ASA 治疗。此外，我们发现维生素 K 拮抗剂抗凝治疗且 INR 处于亚治疗范围内的患者围手术期出血风险没有增加的证据。巩膜扣带术期间应尽可能避免 SRD，且无论采用何种类型的抗凝治疗。
