If you’re living with antiphospholipid syndrome (APS), you’re probably already well aware of how this autoimmune condition adds extra complexity to many aspects of medical care. But when it comes to eye health—especially cataract surgery—APS demands a whole new level of planning and precision. This isn’t just about clearing your vision. It’s about doing so safely while managing the very real risks of clotting and bleeding that come with your diagnosis.
Whether you’re a patient trying to understand the road ahead or a clinician planning a surgical approach, this article walks you through exactly how cataract care must adapt in the context of APS. We’ll talk through anticoagulant management, surgical considerations, and the little details that can make a big difference when endothelial cells and platelet activity are anything but routine.
Understanding APS: The Underlying Thrombotic Landscape
Antiphospholipid syndrome is not a clotting disorder in the traditional sense—it’s an autoimmune condition that promotes abnormal clot formation. The body produces antibodies (particularly lupus anticoagulant, anticardiolipin, and anti-β2 glycoprotein I) that interfere with the normal clotting cascade. These antibodies make the blood more prone to forming dangerous clots in arteries, veins, or small vessels.
When it comes to eye health, this raises two immediate red flags:
- Thrombosis risk during or after surgery – from retinal vein occlusions to more generalised vascular events like stroke or pulmonary embolism.
- Complex anticoagulation status – many patients are already on long-term warfarin, direct oral anticoagulants (DOACs), or low-molecular-weight heparin (LMWH), each with unique implications for eye surgery.
Cataract surgery may be considered minor and routine, but in APS patients, it’s anything but standard.
Preoperative Planning: It Starts with a Thorough Risk Assessment
Before you even think about entering theatre, detailed risk stratification is essential. This includes:
- History of thrombotic events: arterial vs venous, single or recurrent episodes.
- Current anticoagulation regimen: warfarin, DOACs, or bridging therapy?
- Bleeding tendencies: any history of surgery-related haemorrhage, bruising, or excessive bleeding?
- Associated autoimmune diseases: APS often coexists with systemic lupus erythematosus (SLE), which can further complicate healing and inflammation.
Communication between ophthalmologist, haematologist, and anaesthetist is vital. In many cases, haematology input is required to individualise perioperative anticoagulation decisions.
The Importance of Clear Patient Communication: Reassurance Through Understanding
If you’ve been diagnosed with antiphospholipid syndrome, the idea of undergoing surgery—any surgery—can feel overwhelming. It’s easy to get caught up in worry about blood clots, bleeding risks, or how your condition might affect recovery. That’s why one of the most powerful tools in managing cataract surgery for APS patients isn’t just medication or surgical technique—it’s communication. When patients understand exactly why certain decisions are made (such as adjusting anticoagulants or opting for topical anaesthesia), they tend to feel more at ease and engaged in their care.
The best outcomes often come from clinics that take the time to walk you through every step: what to expect before surgery, how your medications will be handled, what to watch for afterwards, and when to call if something feels off. Simple explanations of terms like “posterior capsule opacification” or “INR monitoring” can go a long way in building trust. So, don’t be afraid to ask your surgeon or haematologist any question—big or small. A well-informed patient is a safer patient, and reassurance plays a significant role in recovery.
Balancing Anticoagulation: Risky to Stop, Risky to Continue
Perhaps the most delicate issue in APS cataract surgery is what to do with anticoagulation. Stopping anticoagulants increases the risk of thrombosis, especially in patients with a history of recurrent events. Continuing them raises the likelihood of ocular haemorrhage.
Here are some commonly followed approaches:
- Warfarin: May be continued if the INR is within the therapeutic range (usually 2.0–3.0). If INR exceeds 3.0, adjustment may be needed.
- DOACs: Typically stopped 24–48 hours before surgery depending on renal function and bleeding risk. Bridging is not routinely recommended.
- LMWH bridging: Reserved for high-risk cases (e.g., recent stroke or venous thromboembolism within the last three months).
Ultimately, every case must be managed individually. Some centres prefer to operate under full anticoagulation if the risk of stopping therapy is deemed too high, especially given the generally low bleeding risk of modern phacoemulsification.
The Anaesthetic Plan: Topical, Sub-Tenon, or General?
Anaesthetic choice in APS isn’t just about patient comfort—it’s about vascular integrity and systemic risk.
- Topical Anaesthesia: Often the safest choice, avoiding needles and minimising trauma. It has the lowest risk of retrobulbar haemorrhage.
- Sub-Tenon Block: Can be used cautiously, but requires impeccable haemostasis and preferably normalised coagulation status. If anticoagulation cannot be stopped, this technique may carry increased risk.
- General Anaesthesia: Usually reserved for patients with movement disorders, severe anxiety, or inability to cooperate. Cardiovascular stability must be closely monitored, especially given APS patients’ thrombotic predisposition under general anaesthetic stress.
A detailed discussion with the anaesthesia team is essential before selecting the safest route.
Surgical Challenges: Protecting the Endothelium in APS
Even if you’ve sorted anticoagulation and anaesthesia, the intraoperative phase presents its own hurdles. One of the less talked-about issues in APS is how the endothelium—the single layer of cells lining the inside of the cornea—may be more vulnerable.
Autoantibodies can lead to low-grade endothelial dysfunction. Combine this with phaco energy, irrigation turbulence, or microtrauma, and you’ve got a recipe for postoperative corneal oedema or even endothelial cell loss.
Protective measures include:
- Low phaco energy: Use techniques like phaco chop to reduce ultrasound time.
- Dispersive viscoelastics: To protect the endothelium during surgery.
- Cold irrigation solutions: May help reduce heat damage.
- Shorter surgical time: The quicker, the safer—for both the cornea and clotting profile.
How Systemic Inflammation Can Influence Your Visual Outcome
What many people don’t realise is that APS isn’t just a clotting disorder—it’s also deeply intertwined with systemic inflammation, especially when it overlaps with autoimmune conditions like lupus. This inflammation doesn’t just affect your joints or skin—it can subtly alter the environment inside your eye as well. For example, chronic inflammation may make the ocular surface drier, reduce tear film stability, and slightly impair wound healing after surgery.
Intraocular inflammation—even at a low grade—can increase the risk of complications like cystoid macular oedema (a type of retinal swelling that blurs central vision after surgery). That’s why some patients with APS benefit from preoperative steroid eye drops or non-steroidal anti-inflammatory drugs (NSAIDs) in their post-op regimen. By proactively controlling this inflammation, surgeons can help preserve retinal clarity and reduce the risk of visual distortions after an otherwise technically successful operation. Addressing the systemic nature of APS, not just the ocular elements, is what truly elevates patient outcomes.
Ocular Surface Challenges: Why Dry Eye Deserves Special Attention in APS
APS doesn’t just affect your bloodstream—it can also quietly influence the surface of your eyes. Many patients with antiphospholipid syndrome, especially those who also have lupus or other autoimmune conditions, experience chronic dry eye symptoms. This becomes especially important when planning cataract surgery, because a compromised tear film can lead to blurry vision, fluctuating measurements, and even delayed healing postoperatively.
Before surgery, your ophthalmologist may recommend a tear film assessment using techniques like tear break-up time or ocular surface staining. If dry eye is present, treatment might include lubricating drops, punctal plugs, or short courses of topical anti-inflammatories to optimise the surface before measurements are taken. Why does this matter? Because the intraocular lens (IOL) power calculation—the number that determines your new lens prescription—can be thrown off by surface irregularities. After surgery, maintaining a stable tear film also supports clearer vision and comfort. In APS patients, being proactive about dry eye isn’t a minor detail—it’s a critical step toward achieving the best possible visual outcome.
Postoperative Management: Healing, Haemostasis, and Thrombosis Watch
Just because the surgery’s done doesn’t mean you’re out of the woods. APS-related complications may surface in the days or weeks that follow, often when you least expect them.
- Re-starting anticoagulation: If anticoagulants were stopped, they should be restarted promptly after confirming no active bleeding. Haematology input here is again invaluable.
- Watch for ocular haemorrhage: Especially in the anterior chamber or subconjunctival space.
- Monitor for delayed wound healing: APS, particularly when coexistent with SLE or vasculitis, can delay epithelial recovery.
- Visual outcomes: Usually excellent if all risk factors are managed, but there may be a higher incidence of transient corneal haze or inflammation.
Patient education is key. They should be told to report any sudden vision changes, pain, or flashes immediately—these could indicate vascular events like central retinal artery occlusion or optic neuropathy.
Special Considerations: APS with Lupus, Pregnancy, or Triple Positive Serology
Some patients with APS fall into particularly high-risk categories:
- Lupus overlap: Higher likelihood of scleritis, dry eye, and generalised inflammation. May require steroid cover perioperatively.
- Triple positive antibodies: Lupus anticoagulant, anti-β2 glycoprotein I, and anticardiolipin—together—mark a significantly higher thrombotic risk.
- Pregnancy or fertility treatment: Cataract surgery should be deferred unless vision loss is severe. APS in pregnancy raises risk of miscarriage and thrombotic events.
These situations demand additional precautions and multidisciplinary collaboration.
FAQs
- Can I have cataract surgery if I have antiphospholipid syndrome?
Yes, you can still have cataract surgery if you have antiphospholipid syndrome (APS), but it requires additional planning to manage your clotting risk and any medications you’re on. With the right precautions, outcomes are generally very good. - Should I stop my anticoagulants before the operation?
This depends on your specific risk profile and the type of anticoagulant you’re taking. Never stop anticoagulation without consulting your haematologist and eye surgeon, as stopping too soon may increase your risk of a clot, while continuing may raise bleeding risk. - Is there a higher chance of complications?
There is a modestly increased risk of either bleeding or thrombosis in APS patients during or after surgery, but these risks are well understood and can usually be minimised through careful perioperative planning and appropriate adjustments to your medication. - Will the surgery affect my other autoimmune conditions?
It might, especially if you also have systemic lupus erythematosus or related conditions. Surgery can sometimes trigger inflammation, so your specialist may recommend a course of steroids or other anti-inflammatory measures to reduce the risk of a flare. - How long does healing take after cataract surgery if you have APS?
Healing times are usually similar to those without APS, though you might experience slightly slower recovery in some cases, especially if inflammation or vascular fragility is present. Regular follow-ups will help catch and manage any delays early. - Is topical anaesthesia safe if I’m on blood thinners?
Yes, topical anaesthesia is typically very safe for APS patients, even when taking anticoagulants. It avoids the need for needle-based blocks, which can carry a higher risk of bleeding in patients with altered clotting profiles. - What should I watch for after surgery?
Be alert for any new or worsening eye pain, redness, sudden vision changes, or new floaters, as these could indicate bleeding, inflammation, or a vascular event. Contact your clinic promptly if any of these symptoms appear. - Can cataracts return after surgery?
Not exactly, but you may develop posterior capsule opacification (PCO), a common clouding behind the artificial lens that can affect your vision. This is easily corrected with a quick outpatient laser treatment. - Does APS make my cornea weaker or more vulnerable?
Some research suggests that the endothelial cells in APS patients may be more susceptible to surgical stress or inflammation. Surgeons typically take extra steps—like using dispersive viscoelastics—to protect the cornea during cataract procedures. - Will I need extra follow-up appointments?
You may require a few more follow-up visits than usual to ensure everything is healing well and to monitor for signs of inflammation or vascular complications. These checks are reassuring and help catch any issues early.
Final Thoughts: It’s All About Customisation
There’s no one-size-fits-all strategy when performing cataract surgery on someone with antiphospholipid syndrome. But with careful preoperative planning, precise surgical technique, and individualised anticoagulant management, excellent outcomes are entirely possible.
At the London Cataract Centre, we take these complex cases seriously. Our team works closely with haematologists, anaesthetists, and rheumatologists to ensure every angle is covered—because your eye health is only one part of the puzzle.
References
- Giannakopoulos, B. & Krilis, S.A., 2013. The pathogenesis of the antiphospholipid syndrome. New England Journal of Medicine, 368(11), pp.1033–1044. DOI: 10.1056/NEJMra1112830. [Accessed 23 June 2025].
- Kuriyan, A.E., Srinivasan, S., Sridhar, J. & Huang, A.J., 2020. Perioperative management of anticoagulants in ophthalmic surgery. International Ophthalmology Clinics, 60(4), pp.1–12. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334869/ [Accessed 23 June 2025].
- Chen, C.K., Tseng, V.L. & Greenberg, P.B., 2010. Survey of the management of antithrombotic therapy in cataract surgery patients. Journal of Cataract & Refractive Surgery, 36(7), pp.1239–1240. DOI: 10.1016/j.jcrs.2010.04.021. [Accessed 23 June 2025].
- Day, H.M. et al., 2015. Continuation of anticoagulant and antiplatelet treatment in patients undergoing cataract surgery. Current Opinion in Ophthalmology, 26(1), pp.57–63. Available at: https://journals.lww.com/co-ophthalmology/fulltext/2015/01000/Continuation_of_anticoagulant_and_antiplatelet.7.aspx [Accessed 23 June 2025].