Risk of Hemorrhagic Complications and Secondary Surgery in Patients on Warfarin vs DOACs Undergoing Glaucoma Surgery

Purpose: To compare the risk of postoperative ocular hemorrhagic complications and reoperation in glaucoma surgery patients taking warfarin versus direct oral anticoagulants (DOACs). Patients and Methods: This retrospective cohort study used the TriNetX global federated health research network. We identified 15,336 glaucoma surgery patients on warfarin and 22,358 on DOACs between January 1, 2000 and January 1, 2025. After 1:1 propensity score matching for age, gender, race, Type 2 Diabetes, hypertension, hyperlipidemia, and nicotine dependence, 15,019 patients remained in each cohort. We analyzed postoperative hemorrhagic complications within 1 year, including vitreous, conjunctival, retinal, and choroidal hemorrhages; hyphema; mitomycin injection; and periocular hemorrhage. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated, with significance set at p < 0.05. A secondary analysis assessed reoperation risk among those who experienced hemorrhagic complications. Patients on anticoagulants were compared to glaucoma patients with hemorrhagic complications who were not on anticoagulants. Reoperations included repeat trabeculectomy and aqueous shunt revision/insertion. Results: Warfarin was associated with significantly higher risk of vitreous hemorrhage (RR 1.949, CI 1.563–2.321, p < 0.0001), conjunctival hemorrhage (RR 1.329, CI 1.007–1.710, p = 0.0459), retinal hemorrhage (RR 1.512, CI 1.145–1.997, p = 0.0033), and hyphema (RR 1.740, CI 1.240–2.462, p = 0.0015). No increased risk was found for choroidal hemorrhage or postoperative mitomycin C injection. Hemorrhagic complications did not increase reoperation risk in patients on anticoagulants compared to controls. Conclusion: Warfarin use is linked to higher ocular hemorrhagic complication rates post-glaucoma surgery compared to DOACs. Anticoagulants use did not increase the risk of reoperation.