Preliminary data from a prospective follow-up study underscores the importance of anticipating and managing intraoperative floppy iris syndrome (IFIS), ensuring tamsulosin (Flomax®, Boehringer Ingelheim Pharmaceuticals) patients have successful cataract surgery.

However, it appears many patients and some physicians are unaware that Flomax use, past or present, can complicate cataract surgery.

Other alpha-blockers used to treat benign prostatic hyperplasia (BPH), such as Hytrin, Cardura and Uroxatral, have also been associated with IFIS. Because advance knowledge of alpha-blocker use is essential in reducing complications, patients considering cataract surgery should be screened for these medications, particularly if their pupil dilates poorly.

Any history of Flomax or other alpha-blocker use is important to know because IFIS can still occur in patients who stopped using these drugs several years before cataract surgery. Interestingly, Flomax also is being used off-label to treat women with urinary retention.

In 2005, David F. Chang, MD, and John R. Campbell, MD, identified a link between Flomax, the most commonly used medication to treat BPH, and a new small pupil syndrome they named intraoperative floppy iris syndrome. IFIS characteristics include a billowing and floppy iris, a strong propensity for the iris to prolapse and progressive intraoperative miosis.

They documented increased vitreous loss with IFIS, which has since been reported in patients taking other systemic medications with alpha-1 blocking effects, as well as saw palmetto, an over-the-counter herbal supplement for prostate health.

At the ASCRS Annual Meeting in March, Dr. Chang reported preliminary results of a 10-center study to assess the surgical success and complication rate in patients taking tamsulosin.

The study enrolled 167 consecutive eyes presenting for cataract surgery in patients taking Flomax. Unlike prior retrospective studies, the ophthalmologists knew of tamsulosin use before surgery and used one of four methods to manage the iris:

• Iris retractors

• Pupil expansion rings

• Healon 5 with lowered aspiration parameters

• Preoperative Atropine drops

Surgeons avoided pupil stretching techniques that are ineffective and may exacerbate IFIS, and in the majority of cases, tamsulosin was not discontinued preoperatively. In Dr. Chang's study, managing IFIS as described above reduced the posterior capsular tear rate to less than 1 percent.

"IFIS increases the risk of complications when it is not anticipated," Dr. Chang said. "However, surgeons who are forewarned by a history of alpha-blocker use can achieve excellent surgical outcomes by using alternative pupil management techniques. Patients need not avoid these drugs, but must inform their eye surgeons about their use."

Patient education materials and clinical resources are available on the Academy Web site. In addition, the Academy and ASCRS will issue a joint news advisory in August to inform the public of the new study results and the need for patients to disclose alpha-blocker use to their eye surgeons before cataract surgery.

To learn even more about the issue and how to avoid surgery complications, join the Academy and ASCRS for a member-only "Ask the Experts" conference call featuring IFIS study author Dr. David Chang. Dr. Chang will be joined by a panel of experts who will be available to answer your questions. The call is scheduled for Aug. 17 at 8 p.m. EDT/5 p.m. PDT. Space is limited. To R.S.V.P. for the call, send an e-mail to teleconference@aao.org with your name and Academy member ID number. Call-in details will be e-mailed to you.

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