SMALL INCISION MANUAL ECCE (BLUMENTHAL TECHNIQUE) IN PATIENTS ON WARFARIN THERAPY

1
SMALL INCISION MANUAL ECCE (BLUMENTHAL TECHNIQUE)
IN PATIENTS ON WARFARIN THERAPY

• Yossi Yatziv M.D., Moshe Lazar M.D.
• Tel Aviv Medical Center

2
Background

• The use of Warfarin in the elderly population
  undergoing cataract surgery is not uncommon
• A recent survey done in the U.K. found that 5.1
  of patients undergoing cataract surgery were
  taking Wafarin at the time of surgery1.
• Despite the wide use of oral anticoagulants in
  candidates for cataract surgery the is no
  consensus addressing the issue of whether to
  continue these medications during surgery.

3
Background

• Phacoemulsification is, by far the most widely
  used technique for cataract extraction in
  developed countries.
• Due to the costly machinery and consumables
  manual ECCE is increasingly employed in
  developing countries and has shown to yield
  similar surgical outcomes2.
• In a modern environment, due to the surgeons
  preference or surgical considerations, a
  considerable percentage of cataract extractions
  are done using the manual technique.

4
Background

• Several studies documented the safety of
  phacoemulsification cataract surgery in patients
  on Warfarin therapy3-5.
• A few earlier reports examined the hemorrhagic
  complications in patients undergoing manual ECCE
  cataract surgery4,6-8. they reported only minor
  complications.
• Some of these studies compared the rate of
  hemorrhagic complications between the manual and
  phaco techniques. They concluded that
  phacoemulsification should be the preferred
  technique when performing cataract surgery on
  patient receiving Warfarin4,8.

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Purpose

• The purpose of our study is to examine the rate
  of hemorrhagic complications in patients under
  Warfarin therapy undergoing cataract surgery
  using the small incision manual ECCE (Blumenthal
  technique)

6
Methods

• We retrospectively examined the files of 21
  non-selected patients who underwent cataract
  surgery between the years 2004-2007 using the
  small incision manual ECCE technique while on
  uninterrupted Warfarin (Coumadin, Taro, Israel)
  therapy.
• Patient files were reviewed and data regarding
  the patient systemic illnesses and indication for
  Warfarin therapy was recorded.

7
Methods

• All patients underwent complete ophthalmologic
  and systemic examination.
• Patients were instructed to continue taking all
  their medications, including Warfarin as usual.
• The prothrombine time before surgery was
  determined using the international normalized
  ratio (INR).
• Patients with an INR above 3.0 were excluded from
  the study.

8
Methods

• All surgeries were performed by a single surgeon
  (M.L.) using the small incision manual ECCE
  technique.
• All cases were done under subtenon anesthesia
  with 2 Lidocaine.
• The surgical technique included an anterior
  chamber maintainer and expression of the nucleus
  through a 4-5mm scleral tunnel. An non foldable
  PMMA lens was implanted.
• Records of any intraoperative complications were
  recorded in the postoperative report.
• Patients were examined 1,7 and 30 days
  postoperatively and any late complications were
  noted.

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Results

• The mean age of 8 men and 13 women was 72 years.
• The indications for anticoagulant therapy was
  chronic atrial fibrillation (12 patients),
  artificial valves (6 patients), cardiomyopathy (2
  patients) and deep vein thrombosis (1 patient)
• The mean INR before surgery was 2.1 (0.5)

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Results

• There were no instances of significant bleeding
  during or after surgery.
• 11 patients had postoperative subconjunctival
  hemorrhage which resolved spontaneously.
• The postoperative visual outcome was favorable
  with 82 of the patients achieving visual acuity
  of 20/40 or better at 30 days.

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Conclusions

• This study demonstrates that cataract surgery in
  nonselected patients receiving Warfarin therapy
  (with an INRlt3.0) can be safely performed using
  the small incision manual technique (Blumenthal
  technique).

In memory of Professor Michael Blumenthal
(1935-2007)
12
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