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Taiwan Journal of Ophthalmology 4 (2014) 52e55

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Taiwan Journal of Ophthalmology

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Case report

The use of platelet transfusion in thrombocytopenic patientsfor phacoemulsification

Tsung-Han Lee a,f, Jou-Cheng Huang b,f,g, Kuan-Der Lee c,f,g, Chien-Hsiung Lai b,f,g,San-Ni Chen d,e, Chien-Neng Kuo b,f,g,h,*

aDepartment of Ophthalmology, Chang Gung Memorial Hospital, Kaohsiung, TaiwanbDepartment of Ophthalmology, Chang Gung Memorial Hospital, Chiayi, TaiwancDepartment of Hematology, Chang Gung Memorial Hospital, Chiayi, TaiwandDepartment of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwane School of Medicine, Chung-Shan Medical University, Taichung, TaiwanfChang Gung University College of Medicine, Taoyuan, TaiwangChang Gung University of Science and Technology, Chiayi, TaiwanhDepartment of Ophthalmology, Changhua Christian Hospital, Yun Lin Branch, Yunlin, Taiwan

a r t i c l e i n f o

Article history:Received 21 November 2012Received in revised form24 May 2013Accepted 27 June 2013Available online 22 August 2013

Keywords:cataract surgeryphacoemulsificationplatelet transfusionthrombocytopenia

Conflicts of interest: The authors declare that thefinancial conflicts of interest related to the subject mathe manuscript.* Corresponding author. Department of Ophthalmo

Hospital, No. 6, West, Chia-Pu Road, Putz, Chiayi CouE-mail address: k771376@adm.cgmh.org.tw (C.-N.

2211-5056/$ e see front matter Copyright � 2013, Thhttp://dx.doi.org/10.1016/j.tjo.2013.06.003

a b s t r a c t

Two elderly patients with histories of myelodysplastic syndrome and idiopathic thrombocytopenicpurpura both suffered from blurred vision for a long time and asked for cataract surgery. Due to theirextremely low platelet counts, 5000/mL and 6000/mL, respectively, we administrated 12-unit platelettransfusions each, 2 hours to the surgery. The operations were carried out smoothly, and there were nobleeding-associated complications during these operative procedures. Both patients were satisfied withtheir visual improvement at postoperative 1-week follow up with visual acuity of 0.8 and 1.0, respec-tively, and there was no adverse event reported. From these two cases, we suggested that in patientswith thrombocytopenia, phacoemulsification cataract surgery can be performed with preoperativeplatelet transfusion, producing favorable results without any bleeding-associated complications.Copyright � 2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights

reserved.

1. Introduction

Thrombocytopenia is a common risk factor for surgery. Inphacoemulsification cataract surgery, it can cause serious peri-ocular or intraocular hemorrhage, and leads to severe complica-tions. Although topical anesthesia for phacoemulsification ofsimple cataract with intraocular lens (IOL) implantation was foundto be safe for patients under combined anticoagulant and anti-platelet therapy,1,2 the risk of intraocular bleeding can still be aproblem in complicated cases. Here, we report two cases of patientswith myelodysplastic syndrome and idiopathic thrombocytopenicpurpura with severe thrombocytopenia that had received platelettransfusion 2 hours prior to the phacoemulsification cataract sur-gery, and no bleeding-associated complications were encounteredduring or after the surgery.

y have no financial or non-tter or materials discussed in

logy, Chang Gung Memorialnty 61363, Taiwan.Kuo).

e Ophthalmologic Society of Taiw

2. Case reports

2.1. Case 1

This involved a 60-year-old man with refractory cytopenia withmultilineage dysplasia (myelodysplastic syndrome). His myelo-dysplastic syndrome was diagnosed by bone marrow biopsy 6months 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 ourdepartment due to progressive vision blurring in the right eye for 2months. Best-corrected visual acuity (BCVA) of his right and lefteyes were 0.03 and 0.05, respectively. Slit-lamp examinationrevealed mild dense lens in both eyes with N2C1P1-2 under thegrading of Lens Opacities Classification System III (LOCS III; Fig. 1A).An uneventful phacoemulsification cataract surgery for his righteye was scheduled. However, due to preoperative laboratory dataindicating a platelet level of 5000/mL (the normal range is 150,000e400,000/mL), a 12-unit platelet transfusion was administrated2 hours prior to the surgery. Later, under topical anesthesia,phacoemulsification and subsequent posterior chamber IOL

an. Published by Elsevier Taiwan LLC. All rights reserved.

Fig. 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.

Fig. 2. Case 2, right eye. (A) Preoperative external photo, moderate nuclear sclerosis isnoted. (B) 1-month postoperation: quiet and white conjunctiva without a bleedingevent is noted.

T.-H. Lee et al. / Taiwan Journal of Ophthalmology 4 (2014) 52e55 53

implantationwere performed smoothlywithout any complications.Suture-less wound closure was applied at the end of the operation.There was no further ocular or systemic bleeding episodepostoperatively.

After the operation, his postoperative Day-1 follow-up revealeda favorable wound condition in his right eye with minimal sub-conjunctival hemorrhage, but without periorbital ecchymosis,hyphema, or even choroid hemorrhage (Fig. 1B). At his 1-weekfollow-up, the BCVA of the right eye revealed an improvementfrom 0.03 to 0.8.

2.2. Case 2

This involved a 70-year-old female with steroid refractory se-vere idiopathic thrombocytopenic purpura, who had undergonesplenectomy 7 years previously, but relapsed 5 years later. Afterthat, she received steroid treatment, but with poor response.Therefore, combined treatment with prednisone, imuran, and da-nazol had been initiated 6 months prior to presentation. She wasalso a hepatitis B carrier.

She presented to our outpatient department for progressiveblurring of vision of bilateral eyes. Her initial eye examinationsrevealed best visual acuity of 0.07 in her right eye and 0.08 in herleft eye. Slit-lamp examination revealed a dense lens of both eyeswith N3C1P1 under the grading of LOCS III (Fig. 2A). After obser-vation for 3 months, at the patient’s request, we arranged cataractsurgery for her right eye.

Due to her personal history with steroid refractory thrombo-cytopenic purpura, we carefully checked her blood cell counts priorto the operation, which showed a low platelet level of 6000/mL (thenormal range is 150,000e400,000/mL). In order to correct her

hemostatic condition, we then administered a 12-unit platelettransfusion 2 hours prior to the operation. Following that, she un-derwent phacoemulsification cataract surgery with posterior IOLimplantation under topical anesthesia. Prior to the operation, wemade sure that the pupil of her right eye was well dilated and largeenough to prevent intraoperative iris injury. We also appliedsuture-less wound closure techniques at the end of the operation.The operation went smoothly, and there was no severe or uncon-trolled bleeding noted.

On postoperative Day 1, mild subconjunctival hemorrhage ofher right eye was observed when the wound dressing waschanged (Fig. 2B). Then at her 1-month follow-up clinic, thesubconjunctival hemorrhage in her right eye regressed, and theBCVA of her right eye improved from 0.07 to 1.0. There was nobleeding-associated adverse event reported or found on ocularexamination.

Due to the satisfactory outcome of her right eye, 1 month afterthe surgery on her right eye, cataract surgery was also performedon her left eye (Fig. 3A). This time, after discussion with the he-matologist, we tried to introduce the recently innovated oralthrombopoietic receptor agonist, eltrombopag, however, the pa-tient refused it due to economic reasons. Therefore, we againadministrated a platelet transfusion prior to the phacoemulsifica-tion cataract surgery, and the operation also went smoothly. The 1-week follow-up showed good wound closure without any sign ofprolonged bleeding (Fig. 3B). The optimal BCVA of 1.0 in this eyewas also achieved by 1 month after the operation from a startingpoint of 0.08.

Fig. 3. Case 2, left eye. (A) Preoperative external photo, pharmacologically dilatedpupil, dense nuclear sclerosis with moderate posterior subcortical opacity is noted. (B)1 week postoperation: mild congested conjunctival vessels without presence of sub-conjunctival hemorrhage, hyphema, or other bleeding complications.

T.-H. Lee et al. / Taiwan Journal of Ophthalmology 4 (2014) 52e5554

3. Discussion

Since the early 1990s, phacoemulsification with IOL implanta-tion has become the most popular procedure for cataract surgeonsin most developed countries. Through the introduction of small-incision phacoemulsification, the rate of serious adverse events ofbleeding following cataract surgery has declined over the past fewdecades.3 A previous study of patients using antiplatelet or anti-coagulation medications undergoing cataract surgery, showed nosignificant impact on discontinuing the antiplatelet and anti-coagulation therapy.1 Barequet et al2 also reported that there is noneed to stop the systemic anticoagulant and antiplatelet treatmentprior to the phacoemulsification cataract surgery using a clearcorneal incision under topical needle-free anesthesia.

However, some bleeding-associated complications may still beseen, even with this advanced technique. Due to the insufficienthemostasis, thrombocytopenia has been stated to be a significantrisk factor in ocular surgery for perioperative and postoperativebleedings.4 Therefore, in such cases, sampling blood tests of com-plete blood cell counts are recommended and further preoperativehematologic consultation should be arranged.

In the preparation for surgery, there are many anesthesiamethods currently being used. Among the kinds of anesthesia usedfor cataract surgery, topical anesthesia is the most commonlypracticed and well-accepted choice. However, the debate betweenthe use of topical anesthesia and regional anesthesia have not yetbeen concluded. In a recent meta-analysis of randomizedcontrolled trials, Zhao et al5 stated that although topical anesthesia

can be well tolerated in most cataract surgery, alternative anes-thesia methods are still recommended in specific patients. How-ever, with the approach of regional anesthesia by injection,puncture-related bleeding complications may increase with bothretrobulbar and peribulbar anesthesia, which includes conjunctivalchemosis, sub-conjunctival hemorrhage, periorbital or even retro-bulbal hematoma.5 Therefore, for patients suffering from throm-bocytopenia with prolonged coagulation, the risk of thesebleeding-associated complications may pose a threat to the surgi-cal outcome.

During phacoemulsification cataract operations, the processesthat may result in trauma bleeding should be highlighted andavoided. A stable intraocular pressure and well-formed anteriorchamber during the whole procedure may decrease the possibilityof spontaneous bleeding. However, touching the iris during theoperationmay also increase the risk of subsequent hyphema, whichcan lead to an interruption of the operation and lower the successrate, therefore it should be avoided through careful management.Suprachoroidal hemorrhage has also been reported as a rare vision-threatening complication following incisional intraocular surgery,and its overall incidence ranges from 0.03% to 0.13%.6 The followingconcomitant massive hemorrhage and hemorrhage-induced retinaldetachment should also be explained in patients withthrombocytopenia.

In order to better control the intraoperative bleeding, platelettransfusion in patients with thrombocytopenia is commonly car-ried out in some major operations. The normal platelet count rangeis around 150,000e400,000/mL, and the threshold of 20,000/mL forprophylactic transfusion is widely accepted to prevent spontaneousbleeding.7 For patients undergoing invasive procedures, an optimalplatelet count of >50,000/mL has also been suggested.8 Withregards to platelet transfusion dosage, stable patients without re-fractory to platelet transfusion can be expected to have an increasein platelet count of 5000–7000/mL per unit in a 70-kg adult.9 In ourcases, two patients already met the criteria and showed even lowerfigures than the threshold for platelet transfusions for invasiveprocedures (platelet counts of 50,000/mL), therefore, 12-unitplatelet transfusions were administrated prior to the surgery toovercome the patients’ thrombocytopenic status.

However, transfusion of platelet concentrates may also causesome potential adverse events, such as febrile nonhemolytic trans-fusion reaction, anaphylactic reaction, transfusion related lunginjury, or infection originating from bacterial contamination.9,10

Although the majority of these reactions are not hazardous andmay subside within 30 minutes after the transfusion, the risk offollowing complications shouldbewell informedand close vital signsurveillance, especially body temperature, may be needed once thetransfusion has started.9 If fever, chills, or even vital sign changestake place, the transfusion process should be stopped instantly.

However, the recently developed thrombopoietic receptoragonist, eltrombopag, which was originally proposed to our Case 2for the surgery of her left eye, may be a possible alternative forthose who have thrombocytopenia and are not susceptible totransfusion therapy. As a thrombopoietic receptor agonist,eltrombopag demonstrated its ability to increase platelet count andreduce the need for platelet transfusion in patients with throm-bocytopenia and chronic liver disease who were undergoing anelective invasive procedure.11 Eltrombopag is generally adminis-trated easily in oral form, and it can raise the platelet count after75-mg doses once daily for 14 days. Therefore, we could considerprescribing it for 14 days prior to the cataract surgery if a patienthad experience of adverse transfusion reactions or transfusion-refractory thrombocytopenia. However, increased risks ofthrombosis-related complications have also been reported, and itshould be used cautiously in patients with a history of thrombotic

T.-H. Lee et al. / Taiwan Journal of Ophthalmology 4 (2014) 52e55 55

events.12 After all, the optimal dose, the term of use prior to theoperation, and further surveillance of the long-term benefit is stillrequired, and it is still not recommended over the use of platelettransfusion.

In summary, although perioperative bleeding is no longer amajor concern in phacoemulsification cataract surgery, with somestudies also reporting good results despite defective platelet func-tion and insufficient platelet count,1,2,13 some potential complica-tions may still occur in severely hemostasis-insufficient patientsduring cataract surgery. Although we can manage the operationwith topical anesthesia, better techniques to avoid iris injury, bettermachines to maintain intraocular pressure during the procedure,and suture-less wound closure, further intervention may still beneeded to correct a patient’s baseline hemostasis insufficiency.Therefore, preoperative platelet transfusion may provide somebenefits to a patient’s general condition, which could also make theoperation go more smoothly and with a better outcome bylowering the risk of bleeding-associated complications.

References

1. Kobayashi H. Evaluation of the need to discontinue antiplatelet and anticoag-ulant medications before cataract surgery. J Cataract Refract Surg. 2010;36:1115e1119.

2. Barequet IS, Sachs D, Shenkman B, et al. Risk assessment of simple phaco-emulsification in patients on combined anticoagulant and antiplatelet therapy.J Cataract Refract Surg. 2011;37:1434e1438.

3. Eriksson A, Koranyi G, Seregard S, Philipson B. Risk of suprachoroidal hemor-rhage with phacoemulsification. J Cataract Refract Surg. 1998;24:793e800.

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;36:103e107.

5. Zhao LQ, Zhu H, Zhao PQ, Wu QR, Hu YQ. Topical anesthesia versus regionalanesthesia for cataract surgery: a meta- analysis of randomized controlledtrials. Ophthalmology. 2012;119:659e667.

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8. Navarro JT, Hernández JA, Ribera JM, et al. Prophylactic platelet transfusionthreshold during therapy for adult acute myeloid leukemia: 10,000/mL versus20,000/mL. Haematologica. 1998;83:998e1000.

9. Makroo RN, Kumar P. Platelet transfusions in clinical medicine. Apollo Medicine.2006;3:298e300.

10. Kiefel V. Reactions induced by platelet transfusions. Transfus Med Hemother.2008;35:354e358.

11. Afdhal NH, Giannini EG, Tayyab G, et al. Eltrombopag before proceduresin patients with cirrhosis and thrombocytopenia. N Engl J Med. 2012;367:716e724.

12. Cheng G, Saleh MN, Marcher C, et al. Eltrombopag for management of chronicimmune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study.Lancet. 2011;377:393e402.

13. Kwong YY, Lam RF, Yuen HK, Lam PT, Rao SK, Lam DS. Phacoemulsification inpatients with thrombocytopenia. J Cataract Refract Surg. 2005;31:1846e1847.