Ocular Surgery in Patients With Severe Atherosclerotic Disease: Anesthetic Considerations and Vascular Risk Stratification

Ocular surgery in patients with severe atherosclerotic disease represents a growing clinical challenge due to the increasing prevalence of cardiovascular comorbidities in aging populations. Atherosclerosis, characterized by endothelial dysfunction, inflammation, and arterial stiffness, compromises vascular autoregulation and reduces ocular perfusion, thereby increasing susceptibility to ischemic complications during perioperative hemodynamic fluctuations. In this context, patients undergoing ophthalmic procedures, even those considered low risk, such as cataract surgery, may experience significant cardiovascular and cerebrovascular events. A comprehensive preoperative evaluation is essential and should include detailed cardiovascular history, functional capacity assessment, frailty evaluation, and the use of validated risk indices. Targeted investigations such as electrocardiography, echocardiography, and carotid Doppler imaging allow for the identification of high-risk features and guide perioperative planning. The management of antithrombotic therapy requires an individualized approach that balances thrombotic and bleeding risks, particularly in patients receiving dual antiplatelet therapy or anticoagulation. The choice of anesthetic technique plays a critical role in maintaining hemodynamic stability. Techniques with minimal systemic impact, such as topical anesthesia and Sub-Tenon block, are generally preferred, while general anesthesia should be reserved for selected cases. Intraoperatively, maintaining stable mean arterial pressure, avoiding hypotension and hypertension, and ensuring normocapnia are key strategies to preserve cerebral and ocular perfusion. Postoperative care should focus on early detection of myocardial ischemia, arrhythmias, and neurological complications, as well as timely resumption of antithrombotic therapy. Ultimately, a multidisciplinary and individualized approach is essential to optimize perioperative safety and improve outcomes in this high-risk population.