直接作用型抗凝固薬継続下での白内障術後に創部出血が遷延した1例

A case of prolonged wound bleeding after cataract surgery with continuous direct oral anticoagulant

要約　目的：高齢者はさまざまな全身疾患を有し，抗凝固薬や抗血小板薬内服による抗血栓療法を受けていることも少なくない。アピキサバンは抗凝固薬のうち，直接作用型抗凝固薬（DOAC）に分類されるものである。DOACには凝固能についてのモニタリング指標が存在しない。今回，アピキサバン内服継続下での白内障手術後に，術創からの出血が遷延した症例を経験したので報告する。

症例：82歳，女性。心房細動のためアピキサバン2.5mg/日を内服中であった。術前検査では凝固能はプロトロンビン時間でわずかな延長があったが，その他の指標はすべて基準値内であった。左眼白内障に対し，超音波水晶体乳化吸引術および眼内レンズ挿入術を施行した。切開創は強角膜3面切開で作成した。術後約2時間の時点で術創からの出血を確認しタンポンガーゼで経過をみたが，術翌日も出血が遷延していた。アピキサバン内服を中止した後，止血を確認した。

結論：白内障手術時に抗血栓療法を継続することは望ましいとする報告は多いが，抗血栓療法継続下での眼科手術時の出血性合併症の報告も複数ある。術後の創部出血の遷延は視機能には影響しないが，患者などの不安を煽る可能性もあり，周術期における出血リスクには十分留意する必要があると考えられる。

Abstract　Purpose：Elderly people have various systemic diseases, and antithrombotic therapy with oral anticoagulants and antiplatelet drugs is often performed. Apixaban is classified as a direct oral anticoagulant（DOAC）among others. There is no monitoring index for coagulation ability in DOAC. We report a case of prolonged bleeding from the surgical wound after cataract surgery with continuous oral apixaban.

Case：An 82-year-old woman. She was taking apixaban 2.5 mg/day for atrial fibrillation. Preoperative examination showed a slight prolongation of coagulation ability with prothrombin time, although all other indicators were within the reference values. For left eye cataract, phacoemulsification and intraocular lens insertion were performed. The incision was made by a three-sided corneal incision. Approximately 2 h post the operation, bleeding from the surgical wound was confirmed, and the course was monitored with a gauze tampon, although the bleeding was prolonged the day after the operation. As a result of discontinuing oral apixaban, hemostasis was confirmed.

Conclusion：Although there are many reports that it is desirable to continue antithrombotic therapy during cataract surgery, there are several reports of bleeding complications during ophthalmic surgery with continuing antithrombotic therapy. Postoperative conjunctival bleeding prolongation does not affect visual function, although it may arouse anxiety in patients, and it is necessary to pay sufficient attention to the risk of bleeding during the perioperative period.