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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 52-55

The use of platelet transfusion in thrombocytopenic patients for phacoemulsification


1 Department of Ophthalmology, Chang Gung Memorial Hospital, Kaohsiung; Chang Gung University College of Medicine, Taoyuan, Taiwan
2 Department of Ophthalmology, Chang Gung Memorial Hospital, Chiayi; Chang Gung University College of Medicine, Taoyuan; Chang Gung University of Science and Technology, Chiayi, Taiwan
3 Department of Hematology, Chang Gung Memorial Hospital, Chiayi; Chang Gung University College of Medicine, Taoyuan; Chang Gung University of Science and Technology, Chiayi, Taiwan
4 Department of Ophthalmology, Changhua Christian Hospital, Changhua; School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
5 Department of Ophthalmology, Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Taoyuan; Chang Gung University of Science and Technology, Chiayi; Department of Ophthalmology, Changhua Christian Hospital, Yun Lin Branch, Yunlin, Taiwan

Date of Web Publication4-Mar-2014

Correspondence Address:
Chien-Neng Kuo
Department of Ophthalmology, Chang Gung Memorial Hospital, No. 6, West, Chia-Pu Road, Putz, Chiayi County 61363
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.tjo.2013.06.003

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  Abstract 


Two elderly patients with histories of myelodysplastic syndrome and idiopathic thrombocytopenic purpura both suffered from blurred vision for a long time and asked for cataract surgery. Due to their extremely low platelet counts, 5000/μL and 6000/μL, respectively, we administrated 12-unit platelet transfusions each, 2 hours to the surgery. The operations were carried out smoothly, and there were no bleeding-associated complications during these operative procedures. Both patients were satisfied with their visual improvement at postoperative 1-week follow up with visual acuity of 0.8 and 1.0, respectively, and there was no adverse event reported. From these two cases, we suggested that in patients with thrombocytopenia, phacoemulsification cataract surgery can be performed with preoperative platelet transfusion, producing favorable results without any bleeding-associated complications.

Keywords: cataract surgery, phacoemulsification, platelet transfusion, thrombocytopenia


How to cite this article:
Lee TH, Huang JC, Lee KD, Lai CH, Chen SN, Kuo CN. The use of platelet transfusion in thrombocytopenic patients for phacoemulsification. Taiwan J Ophthalmol 2014;4:52-5

How to cite this URL:
Lee TH, Huang JC, Lee KD, Lai CH, Chen SN, Kuo CN. The use of platelet transfusion in thrombocytopenic patients for phacoemulsification. Taiwan J Ophthalmol [serial online] 2014 [cited 2022 Jan 26];4:52-5. Available from: https://www.e-tjo.org/text.asp?2014/4/1/52/203927




  1. Introduction Top


Thrombocytopenia is a common risk factor for surgery. In phacoemulsification cataract surgery, it can cause serious periocular or intraocular hemorrhage, and leads to severe complications. Although topical anesthesia for phacoemulsification of simple cataract with intraocular lens (IOL) implantation was found to be safe for patients under combined anticoagulant and antiplatelet therapy,[1],[2] the risk of intraocular bleeding can still be a problem in complicated cases. Here, we report two cases of patients with myelodysplastic syndrome and idiopathic thrombocytopenic purpura with severe thrombocytopenia that had received platelet transfusion 2 hours prior to the phacoemulsification cataract surgery, and no bleeding-associated complications were encountered during or after the surgery.


  2. Case reports Top


2.1. Case 1

This involved a 60-year-old man with refractory cytopenia with multilineage dysplasia (myelodysplastic syndrome). His myelodysplastic syndrome was diagnosed by bone marrow biopsy 6 months prior to his outpatient department (OPD) visit. In addition, he was also a hepatitis B carrier. He had no other systemic diseases, such as diabetes mellitus, or hypertension. He was referred to our department due to progressive vision blurring in the right eye for 2 months. Best-corrected visual acuity (BCVA) of his right and left eyes were 0.03 and 0.05, respectively. Slit-lamp examination revealed mild dense lens in both eyes with N2C1P1-2 under the grading of Lens Opacities Classification System III (LOCS III; [Figure 1]A. An uneventful phacoemulsification cataract surgery for his right eye was scheduled. However, due to preoperative laboratory data indicating a platelet level of 5000/μL (the normal range is 150,000–400,000/μL), a 12-unit platelet transfusion was administrated 2 hours prior to the surgery. Later, under topical anesthesia, phacoemulsification and subsequent posterior chamber IOL implantation were performed smoothly without any complications. Suture-less wound closure was applied at the end of the operation. There was no further ocular or systemic bleeding episode postoperatively.
Figure 1: Case 1, right eye. (A) Preoperative external photo, moderate cataract is noted. (B) Postoperative Day 1: there is no developed lid ecchymosis, peribulbar hemorrhage, hyphema or vitreous, retinal or choroidal hemorrhage.

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After the operation, his postoperative Day-1 follow-up revealed a favorable wound condition in his right eye with minimal subconjunctival hemorrhage, but without periorbital ecchymosis, hyphema, or even choroid hemorrhage [Figure 1]B. At his 1-week follow-up, the BCVA of the right eye revealed an improvement from 0.03 to 0.8.

2.2. Case 2

This involved a 70-year-old female with steroid refractory severe idiopathic thrombocytopenic purpura, who had undergone splenectomy 7 years previously, but relapsed 5 years later. After that, she received steroid treatment, but with poor response. Therefore, combined treatment with prednisone, imuran, and danazol had been initiated 6 months prior to presentation. She was also a hepatitis B carrier.

She presented to our outpatient department for progressive blurring of vision of bilateral eyes. Her initial eye examinations revealed best visual acuity of 0.07 in her right eye and 0.08 in her left eye. Slit-lamp examination revealed a dense lens of both eyes with N3C1P1 under the grading of LOCS III [Figure 2]A. After observation for 3 months, at the patient’s request, we arranged cataract surgery for her right eye.
Figure 2: Case 2, right eye. (A) Preoperative external photo, moderate nuclear sclerosis is noted. (B) 1-month postoperation: quiet and white conjunctiva without a bleeding event is noted.

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Due to her personal history with steroid refractory thrombocytopenic purpura, we carefully checked her blood cell counts prior to the operation, which showed a low platelet level of 6000/μL (the normal range is 150,000–400,000/μL). In order to correct her hemostatic condition, we then administered a 12-unit platelet transfusion 2 hours prior to the operation. Following that, she underwent phacoemulsification cataract surgery with posterior IOL implantation under topical anesthesia. Prior to the operation, we made sure that the pupil of her right eye was well dilated and large enough to prevent intraoperative iris injury. We also applied suture-less wound closure techniques at the end of the operation. The operation went smoothly, and there was no severe or uncontrolled bleeding noted.

On postoperative Day 1, mild subconjunctival hemorrhage of her right eye was observed when the wound dressing was changed [Figure 2]B. Then at her 1-month follow-up clinic, the subconjunctival hemorrhage in her right eye regressed, and the BCVA of her right eye improved from 0.07 to 1.0. There was no bleeding-associated adverse event reported or found on ocular examination.

Due to the satisfactory outcome of her right eye, 1 month after the surgery on her right eye, cataract surgery was also performed on her left eye [Figure 3]A. This time, after discussion with the hematologist, we tried to introduce the recently innovated oral thrombopoietic receptor agonist, eltrombopag, however, the patient refused it due to economic reasons. Therefore, we again administrated a platelet transfusion prior to the phacoemulsification cataract surgery, and the operation also went smoothly. The 1 week follow-up showed good wound closure without any sign of prolonged bleeding [Figure 3]B. The optimal BCVA of 1.0 in this eye was also achieved by 1 month after the operation from a starting point of 0.08.
Figure 3: Case 2, left eye. (A) Preoperative external photo, pharmacologically dilated pupil, dense nuclear sclerosis with moderate posterior subcortical opacity is noted. (B) 1 week postoperation: mild congested conjunctival vessels without presence of subconjunctival hemorrhage, hyphema, or other bleeding complications.

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  3. Discussion Top


Since the early 1990s, phacoemulsification with IOL implantation has become the most popular procedure for cataract surgeons in most developed countries. Through the introduction of smallincision phacoemulsification, the rate of serious adverse events of bleeding following cataract surgery has declined over the past few decades.[3] A previous study of patients using antiplatelet or anti-coagulation medications undergoing cataract surgery, showed no significant impact on discontinuing the antiplatelet and anti-coagulation therapy.[1] Barequet et al[2] also reported that there is no need to stop the systemic anticoagulant and antiplatelet treatment prior to the phacoemulsification cataract surgery using a clear corneal incision under topical needle-free anesthesia.

However, some bleeding-associated complications may still be seen, even with this advanced technique. Due to the insufficient hemostasis, thrombocytopenia has been stated to be a significant risk factor in ocular surgery for perioperative and postoperative bleedings.[4] Therefore, in such cases, sampling blood tests of complete blood cell counts are recommended and further preoperative hematologic consultation should be arranged.

In the preparation for surgery, there are many anesthesia methods currently being used. Among the kinds of anesthesia used for cataract surgery, topical anesthesia is the most commonly practiced and well-accepted choice. However, the debate between the use of topical anesthesia and regional anesthesia have not yet been concluded. In a recent meta-analysis of randomized controlled trials, Zhao et al[5] stated that although topical anesthesia can be well tolerated in most cataract surgery, alternative anesthesia methods are still recommended in specific patients. However, with the approach of regional anesthesia by injection, puncture-related bleeding complications may increase with both retrobulbar and peribulbar anesthesia, which includes conjunctival chemosis, sub-conjunctival hemorrhage, periorbital or even retrobulbal hematoma.[5] Therefore, for patients suffering from thrombocytopenia with prolonged coagulation, the risk of these bleeding-associated complications may pose a threat to the surgical outcome.

During phacoemulsification cataract operations, the processes that may result in trauma bleeding should be highlighted and avoided. A stable intraocular pressure and well-formed anterior chamber during the whole procedure may decrease the possibility of spontaneous bleeding. However, touching the iris during the operation may also increase the risk of subsequent hyphema, which can lead to an interruption of the operation and lower the success rate, therefore it should be avoided through careful management. Suprachoroidal hemorrhage has also been reported as a rare visionthreatening complication following incisional intraocular surgery, and its overall incidence ranges from 0.03% to 0.13%.[6] The following concomitant massive hemorrhage and hemorrhage-induced retinal detachment should also be explained in patients with thrombocytopenia.

In order to better control the intraoperative bleeding, platelet transfusion in patients with thrombocytopenia is commonly carried out in some major operations. The normal platelet count range is around 150,000–400,000/μL, and the threshold of 20,000/μL for prophylactic transfusion is widely accepted to prevent spontaneous bleeding.[7] For patients undergoing invasive procedures, an optimal platelet count of >50,000/μL has also been suggested.[8] With regards to platelet transfusion dosage, stable patients without refractory to platelet transfusion can be expected to have an increase in platelet count of 5000–7000/mL per unit in a 70-kg adult.[9] In our cases, two patients already met the criteria and showed even lower figures than the threshold for platelet transfusions for invasive procedures (platelet counts of 50,000/μL), therefore, 12-unit platelet transfusions were administrated prior to the surgery to overcome the patients’ thrombocytopenic status.

However, transfusion of platelet concentrates may also cause some potential adverse events, such as febrile nonhemolytic transfusion reaction, anaphylactic reaction, transfusion related lung injury, or infection originating from bacterial contamination.[9],[10] Although the majority of these reactions are not hazardous and may subside within 30 minutes after the transfusion, the risk of following complications should be well informed and close vital sign surveillance, especially body temperature, may be needed once the transfusion has started.[9] If fever, chills, or even vital sign changes take place, the transfusion process should be stopped instantly.

However, the recently developed thrombopoietic receptor agonist, eltrombopag, which was originally proposed to our Case 2 for the surgery of her left eye, may be a possible alternative for those who have thrombocytopenia and are not susceptible to transfusion therapy. As a thrombopoietic receptor agonist, eltrombopag demonstrated its ability to increase platelet count and reduce the need for platelet transfusion in patients with thrombocytopenia and chronic liver disease who were undergoing an elective invasive procedure.[11] Eltrombopag is generally administrated easily in oral form, and it can raise the platelet count after 75-mg doses once daily for 14 days. Therefore, we could consider prescribing it for 14 days prior to the cataract surgery if a patient had experience of adverse transfusion reactions or transfusionrefractory thrombocytopenia. However, increased risks of thrombosis-related complications have also been reported, and it should be used cautiously in patients with a history of thrombotic events.[12] After all, the optimal dose, the term of use prior to the operation, and further surveillance of the long-term benefit is still required, and it is still not recommended over the use of platelet transfusion.

In summary, although perioperative bleeding is no longer a major concern in phacoemulsification cataract surgery, with some studies also reporting good results despite defective platelet function and insufficient platelet count,[1],[2],[13] some potential complications may still occur in severely hemostasis-insufficient patients during cataract surgery. Although we can manage the operation with topical anesthesia, better techniques to avoid iris injury, better machines to maintain intraocular pressure during the procedure, and suture-less wound closure, further intervention may still be needed to correct a patient’s baseline hemostasis insufficiency. Therefore, preoperative platelet transfusion may provide some benefits to a patient’s general condition, which could also make the operation go more smoothly and with a better outcome by lowering the risk of bleeding-associated complications.

Conflicts of interest: The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript.



 
  References Top

1.
Kobayashi H. Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract surgery. J Cataract Refract Surg. 2010;36: 1115–1119.  Back to cited text no. 1
    
2.
Barequet IS, Sachs D, Shenkman B, et al. Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg. 2011;37:1434–1438.  Back to cited text no. 2
    
3.
Eriksson A, Koranyi G, Seregard S, Philipson B. Risk of suprachoroidal hemorrhage with phacoemulsification. J Cataract Refract Surg. 1998;24:793–800.  Back to cited text no. 3
    
4.
Papamatheakis DG, Demers P, Vachon A, Jaimes LB, Lapointe Y, Harasymowycz PJ. Thrombocytopenia and the risks of intraocular surgery. Ophthalmic Surg Lasers Imaging. 2005;36:103–107.  Back to cited text no. 4
    
5.
Zhao LQ, Zhu H, Zhao PQ, Wu QR, Hu YQ. Topical anesthesia versus regional anesthesia for cataract surgery: a metaanalysis of randomized controlled trials. Ophthalmology. 2012;119:659–667.  Back to cited text no. 5
    
6.
Stein JD. Serious adverse events after cataract surgery. Curr Opin Ophthalmol. 2012;23:219–225.  Back to cited text no. 6
    
7.
Slichter SJ. Relationship between platelet count and bleeding risk in thrombocytopenic patients. Tranfus Med Rev. 2004;18:153–167.  Back to cited text no. 7
    
8.
Navarro JT, Hernández JA, Ribera JM, et al. Prophylactic platelet transfusion threshold during therapy for adult acute myeloid leukemia: 10,000/mL versus 20,000/μL. Haematologica. 1998;83:998–1000.  Back to cited text no. 8
    
9.
Makroo RN, Kumar P. Platelet transfusions in clinical medicine. Apollo Medicine. 2006;3:298–300.  Back to cited text no. 9
    
10.
Kiefel V. Reactions induced by platelet transfusions. Transfus Med Hemother. 2008;35:354–358.  Back to cited text no. 10
    
11.
Afdhal NH, Giannini EG, Tayyab G, et al. Eltrombopag before procedures in patients with cirrhosis and thrombocytopenia. N Engl J Med. 2012;367: 716–724.  Back to cited text no. 11
    
12.
Cheng G, Saleh MN, Marcher C, et al. Eltrombopag for management of chronic immune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study. Lancet. 2011;377:393–402.  Back to cited text no. 12
    
13.
Kwong YY, Lam RF, Yuen HK, Lam PT, Rao SK, Lam DS. Phacoemulsification in patients with thrombocytopenia. J Cataract Refract Surg. 2005;31:1846–1847.  Back to cited text no. 13
    


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