Perioperative Pitfalls: Supplements That Raise Bleeding Risk in Glaucoma Surgery

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Perioperative Pitfalls: Supplements That Raise Bleeding Risk in Glaucoma SurgeryGlaucoma surgery, such as trabeculectomy or tube shunt procedures, requires careful blood clotting to heal properly. Many patients take over-the-counter herbal or dietary supplements for general health or eye health. Some of these supplements – including things like ginkgo biloba, garlic, ginseng, fish oil (omega-3), high-dose vitamin E, and turmeric/curcumin – can “thin the blood”. In other words, they make it harder for blood to clot after an injury. During eye surgery, even a small bleed can lead to serious complications or vision loss. This article reviews which common supplements have blood-thinning effects, what the evidence says about their bleeding risk, how long before surgery they should be stopped, and how doctors can talk to patients about supplement use. We also provide a sample checklist for preoperative visits to make sure supplements are not overlooked.Supplements That Can Thin the BloodMany nutritional supplements and herbal remedies affect blood clotting. Below we describe key supplements known to interfere with platelets or clotting factors, and summarize the evidence about bleeding risk from studies or case reports.Ginkgo BilobaGinkgo biloba is an herbal memory aid that can affect clotting by blocking platelet-activating factor (). In lab tests and animal models it shows antiplatelet and antithrombotic effects (). A small clinical trial found that ginkgo reduced platelet clumping, although standard clotting tests stayed normal (). Importantly, several case reports link ginkgo use to bleeding problems. For example, ginkgo has been reported in isolated cases to cause spontaneous eye bleeds (hyphema) or even brain hemorrhages (). A recent analysis also found that taking ginkgo with other blood thinners (like aspirin or clopidogrel) significantly raised bleeding risk (). In short, evidence suggests ginkgo can increase bleeding, especially when combined with other anticoagulants () (). Many surgeons therefore advise stopping ginkgo well before surgery (often 1–2 weeks prior) to allow its effects to wear off.Garlic (Allium sativum)Garlic supplements are popular for heart health, but garlic can thin the blood. Garlic contains sulfur compounds (like allicin and ajoene) that inhibit platelet aggregation in a dose-dependent way (). Even though large trials have been inconsistent about clinically significant bleeding, several case reports document bleeding issues with high garlic intake (). For example, one report showed that a patient on warfarin had dangerously high INR (over-thinning of blood) after taking garlic supplements (). As a result, experts caution that garlic can add to bleeding risk. Many pre-surgery guidelines recommend stopping garlic about 1 week before an operation to avoid potential clotting problems () ().Ginseng (Panax species)Ginseng root (Asian or American) is an “adaptogen” taken for energy or diabetes, but it can also affect clotting. Laboratory studies have found that ginseng extracts can inhibit platelet aggregation and even prolong clotting times in animals (). In practice, however, reports of bleeding from ginseng are rare. Clinical evidence of ginseng causing hemorrhage is weak: only a f