Aspirin, Blood Thinners and Eye Surgery: Continue or Stop?

Last updated: November 2026

"Should I stop the aspirin?" is one of the commonest questions in the eye OPD. For most eye operations the answer is no: the risk of a stroke, heart attack or stent thrombosis from stopping is far greater than the risk of bleeding in the eye. This page sets out a practical approach by drug and by procedure.

Chart: low-bleeding-risk eye procedures continue antithrombotics; high-risk procedures need a plan with the physician — Decide by the bleeding risk of the procedure and the thrombotic risk of the patient.

Golden rules. Never stop antiplatelets in a patient with a coronary stent placed in the last 12 months, or anticoagulants in a patient with a mechanical heart valve or recent clot, without speaking to the cardiologist or physician. Write down what was decided, by whom, and when the drug restarts.

Step 1: How risky is the procedure?

Bleeding risk	Procedures
Low	Cataract surgery under topical or sub-Tenon anaesthesia; intravitreal injections; corneal surgery; minor lid procedures (chalazion, cyst, lesion biopsy anterior to the septum); strabismus surgery (low to moderate); laser procedures
High	Any surgery under peribulbar or retrobulbar (sharp-needle) block; trabeculectomy and tube surgery; vitrectomy (especially with neovascular disease); orbital surgery and anything behind the orbital septum; blepharoplasty; DCR and lacrimal surgery; enucleation and evisceration; intraocular tumour surgery; temporal artery biopsy

Step 2: What does the patient take, and why?

Drug	Low-risk procedure	High-risk procedure
Aspirin (alone)	Continue	Continue if for secondary prevention (previous MI, stroke, stent, PAD). If for primary prevention only, it can usually be stopped 7 days before.
Clopidogrel (alone)	Continue	As for aspirin; if stopped, 7 days before. Discuss with the physician.
Dual antiplatelet therapy (aspirin + clopidogrel, prasugrel or ticagrelor)	Continue. Avoid sharp-needle blocks: use topical or sub-Tenon anaesthesia.	Defer elective surgery until DAPT is completed (usually 6–12 months after a stent). If surgery cannot wait, the cardiologist decides whether the P2Y12 drug can be paused (clopidogrel and ticagrelor 5–7 days, prasugrel 7 days) while aspirin continues.
Warfarin	Continue. Check INR within 24 hours before surgery; proceed if within the patient's therapeutic range (usually 2.0–3.0). Defer if above range.	Plan with the physician or anticoagulation clinic: stopping 5 days before, with bridging for high thrombotic risk (mechanical mitral valve, recent clot). Check INR on the day.
DOACs (apixaban, rivaroxaban, dabigatran, edoxaban)	Many units continue them for topical or sub-Tenon cataract and injections; others omit the dose on the morning of surgery. A 2019 review suggested a 2-day pause; follow your unit protocol.	Stop 2 days before (longer if kidney function is reduced, especially for dabigatran); restart 1–2 days after surgery once there is no bleeding. No bridging is needed.
Heparins (LMWH for prophylaxis or bridging)	Continue prophylactic doses	Omit the dose before surgery as advised by the physician
Supplements (fish oil, ginkgo, garlic, ginseng, vitamin E)	Continue	Consider stopping a week before; they add to bleeding risk

Step 3: Choose the anaesthesia

Topical or intracameral anaesthesia carries almost no bleeding risk: the first choice for patients on antithrombotics.
Sub-Tenon anaesthesia (blunt cannula) causes minor subconjunctival haemorrhage more often on antithrombotics, but sight-threatening bleeding is rare.
Peribulbar or retrobulbar (sharp-needle) blocks risk a retrobulbar haemorrhage. Avoid them on dual antiplatelets or with an INR above range; if a block is essential, check the INR and apply pressure after the injection.

Restarting

Antiplatelets: usually the same evening or the next day.
Warfarin: the same evening at the usual dose, unless the surgeon advises otherwise.
DOACs: 24–48 hours after surgery once there is no bleeding.
Tell the patient clearly, in writing, when to restart.

Recognising a retrobulbar haemorrhage

Sudden pain, tense proptosis, tight lids, rising IOP and loss of vision after a block or orbital surgery. This is an emergency: perform lateral canthotomy and cantholysis without waiting for imaging if vision is threatened.

Where residents slip

Stopping aspirin "to be safe" in a patient with a recent stent: stent thrombosis can be fatal.
Forgetting to check whether aspirin is for primary or secondary prevention.
Giving a peribulbar block to a patient on dual antiplatelets when topical anaesthesia would do.
Not checking the INR within 24 hours of surgery on warfarin.
Not telling the patient when to restart.

Key sources

Makuloluwa AK, et al. Perioperative management of ophthalmic patients taking antithrombotic therapy. Eye. 2019 (based on Royal College of Ophthalmologists and British Society for Haematology guidance)
Kong KL, Khan J. Ophthalmic patients on antithrombotic drugs: a review and guide to perioperative management. Br J Ophthalmol. 2015;99:1025-1030
Royal College of Anaesthetists and Royal College of Ophthalmologists. Local anaesthesia for ophthalmic surgery: joint guidelines. 2012
Valgimigli M, et al. 2017 ESC focused update on dual antiplatelet therapy. Eur Heart J. 2018;39:213-260

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Written by Dr. Dhaval Patel, MD (Ophthalmology, AIIMS New Delhi)

Consultant, Cataract & Refractive Surgery — among a small number of AIIMS-trained ophthalmologists practicing in Gujarat. Read full credentials & experience or view his 28 publications on ResearchGate.

📚 Also the author of OKAT Decoded and other high-yield ophthalmology exam-prep books used by residents and PG aspirants.

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