If you or a loved one has atrial fibrillation (AF) and is being considered for cataract surgery, you may be wondering how safe the procedure is—especially if you’re taking blood thinners like warfarin or a DOAC (direct oral anticoagulant). It’s a reasonable concern. After all, stopping these medications might raise the risk of stroke, but continuing them could increase the chances of surgical bleeding. So how do ophthalmologists and anaesthetists strike the right balance?
In this article, we’re going to walk you through the key concerns and solutions involved in managing cataract surgery for patients with atrial fibrillation. From preoperative planning to anaesthesia choices and post-op recovery, we’ll look at how healthcare professionals ensure the safest possible outcome.
Understanding Atrial Fibrillation in the Context of Eye Surgery
Atrial fibrillation is the most common cardiac arrhythmia, and its prevalence rises steeply with age—the very same demographic that most often undergoes cataract surgery. In AF, the heart beats irregularly and often too quickly, which increases the risk of stroke due to clot formation. That’s why most AF patients are prescribed anticoagulants.
When it comes to cataract surgery, the procedure itself is low-risk in terms of bleeding. However, the perioperative period still requires thoughtful planning, especially if you’re on anticoagulants. Though we’re not dealing with major incisions or heavy blood loss, small haemorrhages in the eye can still lead to complications, including poor visual outcomes.
The good news is that, with careful coordination between the eye surgeon, GP, cardiologist, and anaesthetist, most AF patients can safely undergo cataract surgery without needing to stop their blood thinners altogether. That said, each case is unique.
Preoperative Assessment: Who’s on the Case?
Before the surgery even gets scheduled, there’s typically a preoperative assessment to determine your overall fitness for cataract surgery. For AF patients, this will include:
- A thorough medical history and list of all medications, particularly anticoagulants and any antiplatelet agents.
- Assessment of stroke risk (often using a tool like the CHA₂DS₂-VASc score).
- Evaluation of bleeding risk, possibly using the HAS-BLED score.
This is also the time when your care team will assess whether your anticoagulation should be continued, paused, or bridged (we’ll discuss this shortly). If you have other cardiac issues—such as a history of heart failure or recent cardiac surgery—these will be factored into your surgical planning too.
DOACs vs Warfarin: What’s the Difference in Cataract Surgery?
DOACs like apixaban, rivaroxaban, dabigatran, and edoxaban have become increasingly popular over the past decade. They have more predictable effects than warfarin and don’t require regular blood tests. But their shorter half-lives mean the timing of the last dose before surgery matters.
For low-bleeding-risk procedures like cataract surgery under topical or local anaesthesia, most guidelines suggest that patients can continue DOACs without interruption. The same is often true for warfarin as long as the INR is within the therapeutic range (typically ≤3.0). However, if general anaesthesia or a block anaesthesia is planned, some adjustments may be needed.
With warfarin, your team may order an INR check a day or two before surgery to confirm it’s safe to proceed. If it’s too high, your dose may be temporarily adjusted.
Timing Anticoagulant Doses Around the Procedure: What Patients Should Know
A crucial but often under-discussed topic is the timing of anticoagulant doses around cataract surgery—especially with DOACs, which have short half-lives and peak activity within a few hours. Many patients aren’t sure whether they should take their morning pill on the day of surgery. The answer often depends on the type of anaesthesia and surgery timing.
If you’re having topical anaesthesia and your procedure is early in the morning, your ophthalmologist may advise taking your DOAC after the operation. This reduces the risk of localised bleeding while still maintaining overall anticoagulant protection. On the other hand, if your surgery is later in the day, there may be more flexibility to take the dose earlier in the morning, especially if the procedure is considered low risk. With warfarin, maintaining a stable INR in the target range is usually the priority, rather than precise timing.
Clear, written instructions should be provided by the surgical team. If you’re ever unsure, never guess—call the clinic and ask. These small details can make a significant difference to both your safety and peace of mind.
Anaesthetic Considerations: Local, Topical, or General?
One of the reasons cataract surgery is so accessible to older and higher-risk patients is that it can often be done under topical anaesthesia (eye drops) or local anaesthetic blocks (such as sub-Tenon’s or peribulbar). This avoids the cardiovascular stress of general anaesthesia, which is particularly useful in people with AF.
Topical anaesthesia is generally the safest choice for anticoagulated patients because it involves minimal tissue trauma. There’s virtually no bleeding risk, and there’s no need to alter anticoagulation at all.
However, if the surgeon opts for a sub-Tenon or peribulbar block (where anaesthetic is injected around the eye), the small risk of local bleeding must be weighed up. In most cases, these blocks are still considered safe while on anticoagulants—especially DOACs—but the decision is always made individually.
General anaesthesia, while rare in cataract surgery, may be considered in anxious patients or those with head tremor or other issues that prevent cooperation. In these cases, cardiovascular monitoring becomes crucial.
Bridging Therapy: Still Needed?
“Bridging” used to be common practice—stopping warfarin and temporarily giving a short-acting anticoagulant like low molecular weight heparin before and after surgery. But this approach has largely fallen out of favour, especially for low-risk surgeries like cataract removal.
In fact, studies now suggest that bridging increases the risk of bleeding without significantly reducing thromboembolic events in most cases. The current thinking is: if the procedure has a low risk of bleeding, and if your stroke risk is high, it’s generally safer to continue your anticoagulation as usual.
That said, if you have mechanical heart valves or a history of recent embolic events, bridging might still be on the table. This is where coordination with your cardiologist really matters.
Managing Antiplatelet Agents in Dual Therapy Patients
Some patients with atrial fibrillation may also be on antiplatelet medications like aspirin or clopidogrel, particularly if they’ve had a recent stent or heart attack. These patients are at increased risk of both bleeding and clotting.
If you’re on dual therapy (e.g., a DOAC plus aspirin), your team may consider stopping one of the agents temporarily—usually the antiplatelet—depending on your overall risk profile and how recent your cardiovascular event was. Again, this isn’t a decision the eye surgeon makes alone. Expect input from your GP and possibly a cardiologist.
Intraoperative Planning: Expecting the Unexpected
During cataract surgery, meticulous technique minimises bleeding, even in anticoagulated patients. But the team is still prepared for the rare complication. For instance, a subconjunctival haemorrhage (a bright red patch in the white of the eye) can look alarming but is typically harmless and self-resolving.
Surgeons often apply pressure after the anaesthetic injection to reduce the chance of bleeding, and they may use minimally invasive instruments that help control microtrauma. If they anticipate any extra risk—for example, if the patient has very thin conjunctiva or is prone to bruising—they may adjust their technique accordingly.
Postoperative Care: Watching for Signs
After surgery, you’ll usually go home the same day. But your team will give you very clear instructions on what to watch for, especially as someone on anticoagulants. Key things to report include:
- Persistent bleeding from the eye
- Sudden vision changes
- Eye pain or swelling
Luckily, these are rare. Most patients on blood thinners recover without any additional complications. Your eye drops (often steroids and antibiotics) are typically the same regardless of your AF status or anticoagulant use.
Follow-up appointments are just as important. They allow your surgeon to monitor healing and make sure everything is on track.
When Surgery Can’t Wait: Emergency Planning
While cataract surgery is usually elective, there are rare situations where it becomes semi-urgent—such as when vision is so poor that the patient is at risk of falls or injury. In these cases, there may be less flexibility in adjusting anticoagulant schedules.
Even so, the team will try to find the safest path forward. For example, they might switch from a DOAC to a shorter-acting one for better control, or they may schedule the surgery for the time of day when anticoagulant levels are lowest.
Educating the Patient: Reducing Anxiety and Improving Outcomes
For many patients with AF, the thought of surgery while taking a blood thinner brings a lot of understandable anxiety. That’s why effective preoperative education plays such a big role in successful outcomes. When patients are given accurate, personalised information about their medication, anaesthetic options, and safety measures, they’re far more likely to feel reassured—and less likely to make mistakes like skipping doses or stopping medications without telling their doctor.
Surgeons and clinic staff can improve outcomes by using plain language to explain why anticoagulants are usually continued, what the risks are, and what will be done to manage them. Visual aids, printed summaries, and even short explainer videos can reinforce these messages. Including family members in the pre-op discussion is also helpful—especially for older patients who may rely on carers for medication management.
Ultimately, empowered patients tend to recover better and report higher satisfaction. For someone with AF facing eye surgery, a little knowledge really does go a long way.
Special Considerations for AF Patients with Additional Risk Factors
Managing cataract surgery in a patient with AF who also has other comorbidities—such as diabetes, renal impairment, or frailty—adds further layers of complexity. Here, a multidisciplinary approach becomes even more valuable.
Patients with chronic kidney disease may have altered drug metabolism, particularly with DOACs, which are renally cleared. Your team may need to adjust your dosage or choose a different agent entirely.
Those with cognitive impairment due to past strokes may also need extra support during the pre-op consent process. Ensuring that the patient understands the procedure and associated risks is not only ethical—it’s legally required.
Frequently Asked Questions (FAQ)
- Can I still have cataract surgery if I have atrial fibrillation?
Yes, most people with atrial fibrillation can safely undergo cataract surgery. The procedure is typically low-risk and can often be done under local or topical anaesthesia, which avoids placing extra strain on your heart. Your healthcare team will work together to adjust or maintain your medications safely, especially if you’re taking blood thinners. - Do I need to stop taking my blood thinner before surgery?
Not always. For most cataract surgeries done under topical or local anaesthesia, anticoagulants like warfarin or DOACs (e.g., apixaban, rivaroxaban) can often be continued. If there’s a higher risk of bleeding or a general anaesthetic is planned, your doctor might suggest modifying the timing or dose, but stopping altogether is rare. - What happens if I miss a dose of my anticoagulant before surgery?
It’s important to follow your doctor’s instructions closely. Missing a dose without guidance can increase your risk of stroke. If you accidentally skip a dose before surgery, contact your surgical or cardiology team right away—they’ll advise on the best next step depending on the timing and type of medication. - Is general anaesthesia safe for someone with AF?
While cataract surgery is usually performed under local anaesthesia, general anaesthesia may occasionally be used in specific situations. For someone with AF, general anaesthesia is generally safe with proper monitoring, but your anaesthetist will assess your individual heart rhythm, medication use, and overall risk before proceeding. - What if I’m also taking aspirin or clopidogrel?
If you’re on antiplatelet medication in addition to a blood thinner—often called dual therapy—your surgical team may need to make some adjustments. They might recommend pausing the antiplatelet temporarily, especially if your bleeding risk is higher. This decision is usually made with input from your cardiologist. - Will taking blood thinners increase the risk of bleeding in my eye?
There is a small risk of bleeding, especially if a local injection (like a sub-Tenon’s block) is used, but it’s generally very low. Most bleeding is minor and cosmetic, such as a subconjunctival haemorrhage (a red spot in the eye), which usually clears on its own. Severe complications are rare with proper planning. - Will I need to stay overnight in hospital?
In most cases, cataract surgery is a day procedure—even for patients with AF. You’ll likely be discharged the same day, provided you’re stable and there are no complications. Make sure someone can accompany you home, and have your medications and eye drops ready to go in advance. - Can I continue all my regular medications on the day of surgery?
You can usually continue most of your regular medications, including those for blood pressure, diabetes, and heart rhythm. The only exception may be your anticoagulant, depending on timing and anaesthesia. Your surgical team should give you specific instructions, and if they haven’t—ask for them. - How do I prepare for the consent process if I have cognitive issues from past strokes?
If you’ve had previous strokes and have memory or understanding difficulties, your team will take extra care to ensure you comprehend the procedure and its risks. In some cases, a family member or legal proxy may be involved. Clear communication is essential, and written materials or visuals can help make things clearer. - Is there anything I can do to reduce my surgical risk?
Yes—keep all your appointments, follow medication instructions carefully, and let your care team know about any recent changes in your health. Managing your blood pressure, staying hydrated, and avoiding over-the-counter drugs like ibuprofen unless approved can all contribute to a smoother surgery and recovery.
Final Thoughts: Coordinated Care is the Key
If you’ve got AF and are considering cataract surgery, don’t be discouraged by your condition. You’re certainly not alone, and most patients in your shoes go on to have successful procedures with minimal disruption to their anticoagulation routine.
The most important thing is to make sure everyone on your care team is communicating. Your eye surgeon, GP, anaesthetist, and cardiologist all play a role in tailoring a safe and effective surgical plan. With clear communication, careful monitoring, and evidence-based decisions, cataract surgery in patients with atrial fibrillation can be managed smoothly and safely.
References
- Steffel, J., Verhamme, P., Potpara, T. S., et al. (2021) ‘The 2021 European Heart Rhythm Association practical guide on the use of non‑vitamin K antagonist oral anticoagulants in patients with atrial fibrillation’, Europace, 23(10), pp. 1612–1676. doi:10.1093/europace/euab065. Available at: https://pubmed.ncbi.nlm.nih.gov/33895845/ (Accessed: 27 June 2025).
- Wong, J., Abrishami, A., El-Beheiry, H., Mahomed, N. N., Roderick, D. and Chung, F. (2007) ‘Topical anesthesia: safety and efficacy for cataract surgery’, Canadian Journal of Anesthesia, 54, pp. 205–210. Available at: https://pubmed.ncbi.nlm.nih.gov/17114707/ (Accessed: 27 June 2025).
- Gogate, P., Ambardekar, P., Kulkarni, S., Deshpande, R. and Joshi, S. (2009) ‘Cataract surgery in patients on long‑term aspirin or clopidogrel therapy’, Journal of Cataract & Refractive Surgery, 35(1), pp. 136–142. doi:10.1016/j.jcrs.2008.09.014. Available at: https://pubmed.ncbi.nlm.nih.gov/19104492/ (Accessed: 27 June 2025).
- El-Gasim, M., Birt, C. M. and Wladis, E. J. (2013) ‘Perioperative management of patients on novel oral anticoagulants in oculoplastic surgery’, Ophthalmic Plastic and Reconstructive Surgery, 29(5), pp. 373–376. doi:10.1097/IOP.0b013e31829ad0b4. Available at: https://pubmed.ncbi.nlm.nih.gov/23900225/ (Accessed: 27 June 2025).