Ophthalmic surgery is commonly performed in older adults, a population in whom atrial fibrillation, venous thromboembolism, valvular heart disease, ischemic heart disease, and previous cerebrovascular events frequently require long-term anticoagulant therapy. The expanding use of direct oral anticoagulants (DOACs), together with continued use of vitamin K antagonists and heparin-based therapy, has made perioperative anticoagulant management an increasingly important issue in ophthalmic practice. Although many eye procedures are associated with limited tissue trauma and modest blood loss, bleeding within the orbit or eye can have disproportionate consequences because even a small haemorrhage in a confined anatomical space can threaten vision [1-5]. Perioperative decision-making therefore requires a balance between two competing hazards. Continuing anticoagulation can increase minor bleeding, including subconjunctival haemorrhage, eyelid ecchymosis, wound oozing, or hyphema. Conversely, unnecessary interruption can expose susceptible patients to stroke, systemic embolism, recurrent venous thromboembolism, or other cardiovascular complications. Contemporary perioperative guidance emphasises assessment of the anticoagulant involved, indication for therapy, renal function, thromboembolic risk, procedural bleeding risk, and need for bridging rather than routine cessation [2]. Ophthalmic-specific reviews similarly recommend that management be tailored to the type of surgery and anaesthetic technique [4,5,7,10]. The bleeding profile is not uniform across ophthalmic procedures. Modern clear-corneal cataract surgery performed under topical anaesthesia is generally considered a low-bleeding-risk intervention, and large cohort data have demonstrated very low rates of serious ocular or systemic events in anticoagulated patients [12,14]. Evidence from patients receiving warfarin indicates that continuation can increase minor self-limiting bleeding without a corresponding increase in vision-threatening complications [11]. More recent data also support the safety of uninterrupted DOAC therapy during uncomplicated phacoemulsification [1,6]. In contrast, vitreoretinal, glaucoma, orbital, and oculoplastic procedures can involve greater tissue manipulation and consequently require a more individualized assessment [4,5,9]. Anaesthetic technique adds another dimension to risk. Topical anaesthesia avoids needle-related orbital trauma, whereas peribulbar and other regional ophthalmic blocks have traditionally raised concern about retrobulbar haemorrhage. Prospective and comparative studies, however, have reported low rates of severe haemorrhagic complications among patients receiving anticoagulants during peribulbar or sub-Tenon’s anaesthesia [8,13]. Practice nevertheless remains variable, reflecting differences in patient risk, local protocols, surgeon preference, and the limited number of prospective real-world studies that simultaneously evaluate bleeding and anaesthetic outcomes [3,5]. The present study was therefore undertaken to evaluate perioperative bleeding risk and anaesthetic outcomes among patients receiving anticoagulant therapy who underwent elective ophthalmic surgery at a tertiary care teaching hospital. The primary objective was to determine the frequency and clinical severity of perioperative bleeding events. Secondary objectives were to describe anticoagulant management, assess regional anaesthetic success and perioperative haemodynamic events, and compare bleeding according to continuation or temporary interruption of anticoagulation and according to anaesthetic technique.

Study design and setting. This prospective observational study was conducted at Government Medical College, Siddipet, Telangana, India, over six months from January 2025 to June 2025. The study evaluated routine perioperative practice without assigning or altering anticoagulant treatment. The reporting approach was planned around clinically relevant bleeding and anaesthetic outcomes in patients undergoing elective ophthalmic procedures. Participants and sampling. Consecutive adult patients receiving systemic anticoagulant therapy and scheduled for elective ophthalmic surgery were screened. Eligible therapies included warfarin, direct oral anticoagulants (apixaban, rivaroxaban, or dabigatran), and low-molecular-weight heparin. Patients were included when complete information on anticoagulant exposure, perioperative management, anaesthetic technique, and early postoperative outcomes was available. Patients who did not meet the predefined eligibility criteria or had incomplete perioperative observations were excluded. Eighty-four patients were assessed, four were excluded, and 80 constituted the final study cohort. A consecutive sampling strategy was used to reduce selective enrolment. Perioperative assessment and anticoagulant management. Preoperative evaluation included age, sex, body mass index, American Society of Anesthesiologists physical status, major comorbidities, indication and type of anticoagulant, and planned ophthalmic procedure. The decision to continue or temporarily interrupt anticoagulation was made by the treating ophthalmology, anaesthesiology, and physician teams according to the anticoagulant used, patient-specific thromboembolic risk, renal function when relevant, and anticipated procedural bleeding risk, consistent with the principle of individualized perioperative management described in contemporary guidance [2,4,5]. Bridging with low-molecular-weight heparin was recorded when used. Timing of postoperative anticoagulant resumption was documented. Anaesthetic and surgical assessment. Anaesthesia consisted of regional ophthalmic block or topical anaesthesia with or without intravenous sedation, according to surgical requirements and clinical judgement. Regional techniques included peribulbar and sub-Tenon’s blocks. Block success, need for supplemental local anaesthetic, conversion to general anaesthesia, intraoperative hypotension or bradycardia, postoperative nausea or vomiting, early postoperative pain, and unplanned prolonged stay were recorded. Previous ophthalmic evidence indicates that serious haemorrhagic events associated with regional techniques are uncommon, although careful observation remains essential in anticoagulated patients [8,13]. Outcome measures. The primary outcome was any clinically apparent perioperative bleeding event, including subconjunctival haemorrhage, eyelid or periorbital ecchymosis, persistent surgical-site oozing, retrobulbar haemorrhage, orbital compartment syndrome, sight-threatening haemorrhage, bleeding requiring re-exploration, or transfusion. Secondary outcomes included regional block performance, haemodynamic events, postoperative pain, thromboembolic complications, and mortality during the early postoperative observation period. Statistical analysis and ethics. Continuous variables were summarized as mean ± standard deviation and categorical variables as frequency and percentage. Group proportions were compared using the Pearson chi-square test when appropriate and Fisher’s exact test when expected cell counts were small. A two-sided P value <0.05 was considered statistically significant. Statistical analysis was performed using SPSS software. Necessary Permissions were obtained before starting the study. Written informed consent was obtained from enrolled participants.

Participant profile A total of 84 patients receiving anticoagulant therapy and scheduled for ophthalmic surgery were assessed for eligibility. Four patients were excluded because of incomplete perioperative data or failure to meet the predefined eligibility criteria. Thus, 80 patients were included in the final analysis. The mean age was 67.4 ± 8.9 years, and 46 (57.5%) patients were male. Fifty-two (65.0%) were classified as ASA physical status II and 28 (35.0%) as ASA III. Hypertension was the most frequent comorbidity, followed by diabetes mellitus and ischemic heart disease (Table 1). Table 1. Baseline clinical characteristics of the study population (n = 80) Characteristic n (%) / Mean ± SD Age, years 67.4 ± 8.9 Male 46 (57.5) Female 34 (42.5) BMI, kg/m² 25.6 ± 3.4 ASA physical status II 52 (65.0) ASA physical status III 28 (35.0) Hypertension 49 (61.3) Diabetes mellitus 31 (38.8) Ischemic heart disease 18 (22.5) Atrial fibrillation 15 (18.8) Previous stroke/transient ischemic attack 8 (10.0) Anticoagulant profile and perioperative management Direct oral anticoagulants were the most frequently used agents, accounting for 45 (56.3%) patients. Apixaban was used by 21 (26.3%), rivaroxaban by 18 (22.5%), and dabigatran by 6 (7.5%). Warfarin therapy was documented in 23 (28.8%) patients and low-molecular-weight heparin in 12 (15.0%). Anticoagulation was continued without interruption in 48 (60.0%) patients and temporarily withheld in 32 (40.0%). Among those in whom therapy was interrupted, anticoagulation was restarted within 24 hours in 25 patients and between 24 and 48 hours in seven. Bridging anticoagulation was used in five (6.3%) patients (Table 2). Table 2. Anticoagulant therapy and perioperative management (n = 80) Variable n (%) Warfarin 23 (28.8) Apixaban 21 (26.3) Rivaroxaban 18 (22.5) Dabigatran 6 (7.5) Low-molecular-weight heparin 12 (15.0) Anticoagulant continued perioperatively 48 (60.0) Anticoagulant temporarily withheld 32 (40.0) Bridging anticoagulation used 5 (6.3) Anticoagulation restarted within 24 h 25 (31.3) Anticoagulation restarted at 24–48 h 7 (8.8) Surgical and anaesthetic characteristics Cataract surgery was the most common procedure, performed in 55 (68.8%) patients. Vitreoretinal procedures accounted for 13 (16.3%), glaucoma surgery for 8 (10.0%), and other ophthalmic procedures for 4 (5.0%). Regional ophthalmic anaesthesia was used in 58 (72.5%) patients, including peribulbar block in 38 and sub-Tenon’s block in 20; topical anaesthesia with or without intravenous sedation was used in 22 (27.5%). The mean duration of surgery was 43.7 ± 18.6 minutes. Supplemental intravenous sedation was required in 17 (21.3%) patients, and no patient required conversion to general anaesthesia (Table 3). Table 3. Surgical and anaesthetic characteristics (n = 80) Characteristic n (%) / Mean ± SD Cataract surgery 55 (68.8) Vitreoretinal surgery 13 (16.3) Glaucoma surgery 8 (10.0) Other ophthalmic procedures 4 (5.0) Regional ophthalmic anaesthesia 58 (72.5) Peribulbar block 38 (47.5) Sub-Tenon’s block 20 (25.0) Topical anaesthesia ± sedation 22 (27.5) Supplemental IV sedation required 17 (21.3) Duration of surgery, min 43.7 ± 18.6 Conversion to general anaesthesia 0 Perioperative bleeding outcomes Any perioperative bleeding event was recorded in 13 of 80 patients (16.3%). Most events were minor and self-limiting. Subconjunctival haemorrhage was the most frequent event, occurring in 8 (10.0%) patients, followed by eyelid or periorbital ecchymosis in 4 (5.0%). One patient (1.3%) developed persistent minor surgical-site oozing that was controlled with local measures. No retrobulbar haemorrhage, orbital compartment syndrome, sight-threatening haemorrhage, bleeding requiring re-exploration, or blood transfusion occurred (Table 4). Table 4. Perioperative bleeding outcomes (n = 80) Outcome n (%) Any perioperative bleeding event 13 (16.3) Subconjunctival haemorrhage 8 (10.0) Eyelid/periorbital ecchymosis 4 (5.0) Persistent minor surgical-site oozing 1 (1.3) Retrobulbar haemorrhage 0 Orbital compartment syndrome 0 Sight-threatening haemorrhage 0 Bleeding requiring re-exploration 0 Blood transfusion 0 Bleeding occurred in 9 of 48 patients (18.8%) whose anticoagulant therapy was continued and in 4 of 32 (12.5%) whose therapy was temporarily interrupted; this difference was not statistically significant (P=0.458). Bleeding was recorded in 11 of 58 patients (19.0%) receiving regional ophthalmic anaesthesia and in 2 of 22 (9.1%) receiving topical anaesthesia. Because of small expected cell counts, Fisher’s exact test was used for this comparison; the difference was not statistically significant (P=0.498) (Table 5). Table 5. Association of perioperative bleeding with anticoagulant management and anaesthetic technique Comparison Bleeding n/N (%) No bleeding n/N (%) P value Anticoagulant continued 9/48 (18.8) 39/48 (81.3) 0.458* Anticoagulant interrupted 4/32 (12.5) 28/32 (87.5) Regional ophthalmic anaesthesia 11/58 (19.0) 47/58 (81.0) 0.498† Topical anaesthesia ± sedation 2/22 (9.1) 20/22 (90.9) *Pearson chi-square test. †Fisher’s exact test. A P value <0.05 was considered statistically significant. Anaesthetic and early postoperative outcomes Among the 58 patients receiving regional ophthalmic anaesthesia, the block was successful without supplementation in 56 (96.6%); two (3.4%) required additional local anaesthetic. Transient intraoperative hypotension occurred in 6 (7.5%) patients and bradycardia in 3 (3.8%). Postoperative nausea or vomiting occurred in 3 (3.8%). Sixty-nine (86.3%) patients reported an early postoperative numerical rating scale pain score ≤3. Two patients (2.5%) required unplanned admission or prolonged observation. No early thromboembolic complication or mortality was recorded (Table 6). Table 6. Anaesthetic and early postoperative outcomes (n = 80) Outcome n (%) Successful regional block without supplementation* 56/58 (96.6) Supplementary local anaesthetic required* 2/58 (3.4) Conversion to general anaesthesia 0 Intraoperative hypotension 6 (7.5) Intraoperative bradycardia 3 (3.8) Postoperative nausea/vomiting 3 (3.8) Early postoperative pain score ≤3 69 (86.3) Unplanned hospital admission/prolonged stay 2 (2.5) Thromboembolic complication 0 Mortality 0 *Calculated among the 58 patients who received regional ophthalmic anaesthesia. Overall, 67 of 80 patients (83.8%) completed surgery without a documented perioperative bleeding event. All 80 procedures were completed without conversion to general anaesthesia, sight-threatening haemorrhage, re-exploration for bleeding, transfusion, early thromboembolic complication, or death.

The present prospective observational study examined perioperative bleeding and anaesthetic outcomes in 80 anticoagulated patients undergoing a range of ophthalmic procedures. The principal finding was that bleeding events occurred in 16.3% of patients, but all were minor and managed conservatively. Subconjunctival haemorrhage and limited eyelid or periorbital ecchymosis accounted for nearly all events. No patient developed retrobulbar haemorrhage, orbital compartment syndrome, sight-threatening bleeding, required re-exploration or transfusion, or experienced an early thromboembolic event. These findings reinforce the distinction between visible minor ocular bleeding and clinically consequential haemorrhage when perioperative risk is assessed. The observed pattern is broadly consistent with previous cataract-surgery literature. Katz et al. reported very low absolute rates of ophthalmic and systemic complications in a large prospective cohort of cataract procedures, with little difference attributable to perioperative alteration of aspirin or warfarin therapy [14]. A systematic review by Jamula et al. found that continued warfarin was associated with more bleeding, but the events were predominantly self-limiting subconjunctival haemorrhage or small hyphema without visual compromise [11]. Similarly, Benzimra et al. identified increased minor local-anaesthetic or subconjunctival bleeding among warfarin users without an increase in potentially sight-threatening complications [12]. More recent evidence extends this reassurance to DOACs; Maytal et al. reported no significant excess of intraoperative or postoperative bleeding with uninterrupted DOAC therapy during cataract surgery [1], while Barequet et al. also described uncomplicated phacoemulsification without clinically important haemorrhage in patients receiving NOACs [6]. In the current study, bleeding occurred in 18.8% of patients who continued anticoagulation and 12.5% of those in whom therapy was interrupted, a difference that was not statistically significant. This result should not be interpreted as proof of equivalence because treatment decisions were not randomized and the sample was limited. Nevertheless, it is compatible with ophthalmic reviews emphasizing individualized management rather than routine interruption [4,5,7,10]. The 2022 CHEST guideline likewise supports procedure-specific decisions and discourages indiscriminate perioperative bridging, particularly in atrial fibrillation [2]. Only five patients in this cohort received bridging therapy. Regional ophthalmic anaesthesia was successful without supplementation in 96.6% of cases, and no patient required conversion to general anaesthesia. Bleeding was numerically more frequent after regional block than after topical anaesthesia, but the difference was not significant. Calenda et al. reported no increase in sight-threatening haemorrhage among 750 anticoagulated patients receiving peribulbar anaesthesia [8]. Kumar et al. similarly observed increased subconjunctival haemorrhage with warfarin during sub-Tenon’s anaesthesia but no sight-threatening complication [13]. These observations support careful technique and monitoring rather than assuming that anticoagulation alone precludes regional ophthalmic anaesthesia. The low frequency of haemodynamic disturbance, postoperative nausea or vomiting, and unplanned prolonged stay further indicates generally favourable anaesthetic recovery in this cohort. Because the study included cataract, vitreoretinal, glaucoma, and other procedures, its findings reflect routine mixed ophthalmic practice. However, procedure-specific bleeding risks remain important, particularly for operations involving greater tissue manipulation, as shown in vitreoretinal literature [9]. LIMITATIONS This study has several limitations. The single-centre design and modest sample size restrict generalizability and reduce power to detect rare sight-threatening haemorrhage or thromboembolic events. Anticoagulant continuation or interruption was determined clinically rather than through random allocation, introducing treatment-selection confounding. The cohort combined different ophthalmic procedures and anticoagulant classes, limiting procedure-specific comparisons. Follow-up focused on early perioperative outcomes rather than delayed complications.

Among anticoagulated patients undergoing elective ophthalmic surgery, perioperative bleeding was relatively frequent but predominantly minor, self-limiting, and clinically manageable. No retrobulbar haemorrhage, orbital compartment syndrome, sight-threatening bleeding, surgical re-exploration, transfusion, early thromboembolic event, or mortality was observed. Continuation of anticoagulant therapy was not associated with a statistically significant increase in bleeding compared with temporary interruption. Regional ophthalmic anaesthesia showed a high success rate, with no conversion to general anaesthesia. These findings support individualized perioperative anticoagulant planning that considers the drug, thromboembolic indication, surgical bleeding risk, and anaesthetic technique. Larger multicentre prospective studies with procedure-specific analyses and longer follow-up are needed to define uncommon serious complications more precisely within routine practice.

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