In Reply

Letters to the Editor Cataract Surgery—Indications, Techniques, and Intraocular Lens Selection by Prof. Dr. med. Thabo Lapp, PD Dr. med. Katrin Wacker, Prof. Dr. med. Carsten Heinz, Prof. Dr. med. Philip Maier, Prof. Dr. med. Philipp Eberwein, and Prof. Dr. med. Thomas Reinhard in issue 21–22/2023

We thank our correspondent for his interest in our article (1). He criticizes that the study by Eke et al., which we cite (2), does not provide sufficient evidence for the recommendation that patients on anticoagulation should have their anticoagulation temporarily stopped ahead of a planned injection anesthesia, if this can be justified from an internist’s point of view. We agree with Dr. Stammen that the study cited does not differentiate whether bleeding was more frequent in anticoagulated patients, but we maintain that our conclusion—that bleeding is more likely with anticoagulation—is justified. This discussion is not new in ophthalmology in Germany (3) and is probably still not sufficiently clarified. We agree with the author that the evidence for the individual types of anesthesia in cataract surgery is unsatisfactory. We are not aware of any publications on this topic that include larger groups of patients and a validated study design, nor of any randomized controlled trials other than those cited in our article.

Our recommendation means that we do not give retrobulbar injections to patients on anticoagulants because of the increased risk of bleeding. In exceptional cases, such as when antioagulation cannot be stopped and there are no other options for anaesthesia, the potentially increased risks should be explicitly discussed with the patient. This approach is consistent with Castello and Neth’s Empfehlungen zur anästhesiologischen Versorgung in der Ophthalmochirurgie [recommendations for anesthesiologic care ion ophthalmic surgery] in the version of 3 March 2021 (revision by H Hoerauf et al. for the working circle of the German Society of Ophthalmology [DOG], the German Association of Ophthalmic Surgeons [BDOC], and the Professional Association of German Ophthalmologists [BVA]).

The discussion ultimately substantiates our key message, that even in the absence of high quality evidence, drop anesthesia is to be preferred over injection anesthesia in uncomplicated cataract operations and that better evidence is needed.

DOI: 10.3238/arztebl.m2023.0194

On behalf of the authors

Prof. Dr. med. Thabo Lapp

Klinik für Augenheilkunde

Universitätsklinikum Freiburg, Medizinische Fakultät

Albert-Ludwigs-Universität Freiburg

Conflict of interest statement

The authors of both contributions declare that no conflict of interest exists.

References

1. Lapp T, Wacker K, Heinz C, Maier P, Eberwein P, Reinhard T: Cataract surgery— indications, techniques, and intraocular lens selection. Dtsch Arztebl Int 2023; 120: 377–86

2. Eke T, Thompson JR: Serious complications of local anaesthesia for cataract surgery: a 1 year national survey in the United Kingdom. Br J Ophthalmol 2007; 91: 470–5

3. Feltgen N, Hoerauf H, Noske W, Hager A, Koscielny J: [Platelet aggregation inhibitors and anticoagulants during ophthalmic interventions]. Ophthalmol Z Dtsch Ophthalmol Ges 2016; 113: 1010–22