Amongst all surgeries, cataract surgery is the most commonly performed operation in the United States and perhaps in the world. The introduction of modern technology, including the insertion of implant lenses for the restoration of vision, has made it one of the most successful and satisfying of all surgeries with an extremely low complication rate. Therefore, it would not be surprising if many patients with cirrhosis were found to be candidates for this ophthalmic procedure. Particularly if they happen to also have diabetes mellitus or have been treated with corticosteroids, both are risk factors for cataract formation.

As with all surgeries in patients with cirrhosis, there is the increased risk of bleeding due to a reduction in procoagulant factors. A review of the literature revealed a paucity of reports regarding spontaneous ocular hemorrhage in cirrhotic patients with decompensated liver function [1, 2]. There are no published studies that specifically evaluated the propensity for bleeding during or following routine ophthalmic surgeries in cirrhotic patients with coagulopathy. For the purposes of this chapter, studies documenting the risk of hemorrhagic events in systemic hypocoagulable states such as anticoagulant and antiplatelet medications as well as thrombocytopenia were reviewed for their relationship with ophthalmic surgery.

Two major factors must be taken into consideration when evaluating a patient with cirrhosis for ocular surgery. As the majority of eye surgeries are performed under local anesthesia with intravenous sedation, it is very important to assess the cirrhotic patient for their ability to lie comfortably in a supine position for the duration of the operation. Depending on the nature of the surgery, it may take minutes to hours to perform. If the cirrhosis is advanced and the patient has significant ascites, it may be very difficult if not impossible for them to be placed in a supine position. General anesthesia may be an option in this case, but it is accompanied with increased risk. The other major factor of importance, when planning surgery for patients with cirrhosis, is to assess their propensity for abnormal bleeding. This factor should also be considered when selecting the type of anesthesia and the surgical technique.

The anesthetic techniques for ophthalmic surgical procedures have changed dramatically in recent decades. There are two options for local anesthesia of the eye: topical or an injection into the retrobulbar or peribulbar space. Local anesthesia was used in 46% of ophthalmic surgical procedures in 1993, increased to more than 95% in 2003 [3, 4]. In part, this is due to advances in eye surgery that have allowed for increased efficiency and safety and shorter operating times. There have also been advances in the medications used for intravenous sedation as well. Cataract surgery is now more commonly performed with topical anesthesia (tetracaine 0.5%) alone or topical combined with an intracameral injection (nonpreserved lidocaine 1%) for which there is no risk of bleeding [4]. In one study, patients experienced similar total pain and intraoperative discomfort for procedures under topical compared to retrobulbar/peribulbar anesthesia [5].

Retrobulbar anesthesia is typically delivered via a hypodermic needle into the muscle cone behind the eye. There are a number of potential complications with this technique including perforation of the globe and possibly the optic nerve. In addition, there is the risk of a retrobulbar hemorrhage that is increased in a patient with a hypocoagulopathy. A retrobulbar hemorrhage after retrobulbar or peribulbar anesthesia secondary to an arterial perforation can have overwhelming outcomes such as optic nerve and retinal ischemia and subsequently severe visual loss. In cases with a hypocoagulopathy, whenever possible, alternative anesthesia techniques including subconjunctival [6, 7] sub-Tenon [8], topical [9–11], and intracameral [12] should be considered. One study reported a reduced risk of hemorrhagic complications with topical anesthesia when compared with retrobulbar or peribulbar anesthesia, especially in individuals with preexisting systemic conditions [13]. Longer ophthalmic procedures that require more manipulation of the eye, such as retinal detachment repair cannot be performed under topical and require retrobulbar anesthesia. To reduce the risk of a retrobulbar hemorrhage, rather than the use of a sharp needle, a blunt-tipped catheter can be inserted into the muscle cone through a conjunctival incision. This technique is preferred for patients with any type of bleeding diathesis. General anesthesia has its own associated risks but avoids the potential complications of a retrobulbar injection. It is usually reserved for longer surgeries such as pediatric, or ocular trauma procedures, or for patients with anxiety or claustrophobia [14].

A tragic hemorrhagic complication specific to intraocular surgery is the expulsive choroidal hemorrhage. This rare adverse event usually leads to either loss of vision or even loss of the eye. Although it is commonly associated with cataract surgery, it can occur with any penetrating ocular surgery such as a glaucoma procedure, corneal transplantation, and retinal surgery. A British national survey reported an incidence of 0.04% for suprachoroidal hemorrhage during cataract extraction [15]. The primary risk factors for this devastating hemorrhagic event include systemic parameters causing arterial fragility such as arterial hypertension, arteriosclerosis, advanced age, and diabetes [16, 17]. Ocular factors associated with an increased risk for the development of a suprachoroidal hemorrhage include choroidal sclerosis, glaucoma, myopia, prolonged intraocular surgery, and hypotony [17].

In the past few decades, there has been a dramatic technological leap for cataract surgery. Phacoemulsification (ultrasound energy) has become the most commonly applied technique in developed countries, allowing for smaller incisions within a closed more stable eye and shorter operating time. In a series of 51 eyes corresponding to 40 patients at high risk for thromboembolic complications, phacoemulsification surgery with IOL implantation using a clear corneal incision under topical needle-free anesthesia was safely performed without discontinuing anticoagulation or antiplatelet therapy [18]. Cataract extraction with modern techniques can safely and effectively be performed in patients who are warfarinized with an INR of approximately 2.0 [19]. The incidence of suprachoroidal hemorrhage during cataract surgery has markedly decreased from 0.13% in extracapsular extractions (large incision) to 0.03% in phacoemulsification [20]. Studies have failed to show an increased risk of hemorrhagic complications in the perioperative period for cataract surgery when patients were treated with antiplatelet (aspirin or clopidogrel) or anticoagulant therapy [18, 21–24]. Phacoemulsification techniques with the insertion of foldable intraocular lenses (IOLs) through avascular clear corneal incisions under topical anesthesia have elevated cataract extraction surgery into a lower-risk procedure [25]. Therefore, one should expect similar results for a cirrhotic patient with a hypocoagulopathy.

There are a number of indications for vitreoretinal surgery including the repair of retinal detachments, treatment of advanced diabetic retinopathy, and surgery for some macular conditions. Unlike cataract surgery that can be performed through an avascular cornea, vitreoretinal procedures require conjunctival and scleral incisions. In addition, occasionally, an incision may be necessary in the highly vascularized retina and choroid. In recent years, a number of studies have evaluated the risk of bleeding in patients undergoing vitreoretinal surgery while on anticoagulant therapy [26–30]. A review of 57 vitreoretinal surgical procedures performed on patients treated with warfarin, there were no cases of anesthesia-related or intraoperative hemorrhage [28]. In another series evaluating the risk of bleeding in vitrectomy surgery, 60 patients treated with warfarin had a median INR of 2.3 ranging up to 4.6, without an increase in perioperative complications [30]. Fu et al. reported on 25 scleral buckle surgeries treated with warfarin anticoagulation. Retrobulbar or peribulbar anesthesia was administered and only one intraoperative subretinal hemorrhage was observed during external drainage of subretinal fluid [29]. Nonetheless, it is prudent to avoid external drainage of subretinal fluid whenever possible in anticoagulated patients. Antiplatelet usage has also been studied in this setting, and it is not considered a risk factor for bleeding [31–34]. Advances in vitreoretinal surgery include a shift from 20-gauge incisions to smaller entrance ports (23, 25, and 27gauge). Consequently, there is decreased risk of bleeding with shorter surgical time, and in select cases, it is feasible to use alternative methods of anesthesia such as subconjunctival or sub-Tenon injections that avoid the risks associated with retrobulbar injections [35].

Intravitreal injections of various medications for a variety of indications have been established as a treatment modality for a number of retinal pathologies. The MARINA and ANCHOR clinical trials for macular degeneration have shown that the anti-VEGF inhibitor ranibizumab can be safely injected into eyes of patients on warfarin anticoagulation and ASA antiplatelet therapy [36, 37].

A rather sudden, marked reduction in intraocular pressure from glaucoma surgery predisposes the eyes to an intra- or postoperative suprachoroidal hemorrhage. Anticoagulation can only exacerbate the extent of a suprachoroidal hemorrhage, making a difficult complication even worse. In a retrospective study reviewing 367 trabeculectomies, none of the 55 patients on aspirin experienced a significant intraoperative or postoperative hemorrhage. Aspirin was associated with a significantly higher risk of hyphema but without significant influence on intraocular pressure at 2 years. In this study, all of the five patients on warfarin suffered hemorrhagic complications (two required reoperation for hyphema evacuation) and four had trabeculectomy failure [38]. These results were confirmed by another retrospective study on eyes undergoing glaucoma surgery [39].

Overall, the incidence of severe hemorrhagic complications is low in oculoplastic procedures. In a survey the incidence of orbital hemorrhage associated with cosmetic eyelid surgery was 0.055% (1/2000), and orbital hemorrhage with permanent visual loss was 0.0045% (1/10,000) [40].

In a prospective study, serious bleeding with the potential to affect surgical outcome, occurred in 0.4% of oculoplastic surgeries, but neither hepatic cirrhosis nor consumption of anticoagulants and antiplatelet agents were reported as risk factors for bleeding or bruising [41]. In a series of 150 dacryocystorhinostomy procedures, two patients with preexisting clotting abnormalities were found to have significant postoperative bleeding [42].

In patients with cirrhosis, dry eye syndrome is a particularly common problem [43, 44]. Seventy-eight percent of patients with primary biliary cirrhosis were shown to have ocular surface dryness confirmed by tear-film breakup time and Rose Bengal staining [45]. The dry eye syndrome is a multifactorial disease of the tear film and ocular surface. It can result in symptoms of discomfort, visual disturbance, and tear-film instability with potential damage to the ocular surface, and possible ulceration. Advanced stages of hepatic fibrosis have been correlated with subjective and objective signs of dry eye. It has been hypothesized that as hepatic fibrosis progresses, there is a decrease in the synthesis of essential factors such as vitamin A and growth factors that are necessary for healthy tear film and ocular surface [46]. Tear production is decreased in HCV infection, possibly as a result of lymphocytic infiltration of the lacrimal gland [47]. An impairment of tear dynamics and squamous metaplasia in the ocular surface has been reported in patients with chronic hepatitis C treated with interferon alpha-2b and ribavirin. Moreover, it is emphasized that these abnormalities may persist even 6 months after discontinuation of treatment [48].