Download Flomax and Floppy Iris Syndrome

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INTRAOPERATIVE FLOPPY IRIS SYNDROME (IFIS)
and FLOMAX
I
ntraoperative Floppy Iris Syndrome (IFIS) is a complication that can occur during cataract surgery in a
small number of patients. This syndrome is most closely
associated with the use of Flomax (tamsulosin), a medication widely prescribed to relieve the urinary symptoms
caused by an enlarged prostate. Although most commonly
associated with Flomax, IFIS can also be caused by similar
drugs such as Cardura (doxazosin), Hytrin (terazosin),
and Uroxatrol (alfuzosin).
Mechanism of action
Flomax and the other drugs listed above work by blocking
the Alpha-1A receptors of the smooth muscle cells in the
bladder and prostate, thereby decreasing muscle contraction in the bladder and enlarged prostate and increasing
urinary flow.
These drugs can also affect smooth muscle cells found in
other tissues of the body such as blood vessel walls and the
iris of the eye. Cardura (doxazosin), for example, can be
used to treat both high blood pressure as well as urinary
outflow restriction. Although the effect of these drugs is
relatively specific to the bladder and prostate, all of these
drugs have some degree of side-effect on the smooth
muscle cells of the iris, causing poor dilation of the pupil
and loss of muscle tone with a floppy billowing iris.
Complications during cataract surgery
In routine cataract surgery the pupil is widely dilated and
the cataractous lens is removed using a technique called
phacoemulsification wherein a special ultrasound probe
is inserted through a small incision and used to break up
the cataract. A constant stream of fluid through the probe
is used to keep the ultrasound tip cool and to irrigate the
emulsified cataract particles out of the eye.
In an eye with Intraoperative Floppy Iris Syndrome (IFIS),
the iris billows wildly in response to the irrigating fluid
and has a tendency to become entrapped in the probe
tip or to blow out of the cataract incision. This tendency
is made worse by poor pupillary dilation and progressive
pupillary constriction during the course of the surgery.
These actions make cataract surgery much more difficult
for the surgeon and despite great surgical care the iris or
pupil can be damaged. Patients with IFIS may also experience more discomfort during surgery, a longer recovery
period and less initial improvement in visual acuity than
a patient with uncomplicated cataract surgery.
Management of IFIS
The effect of Flomax and related drugs on the iris appears to be long-lasting and possibly permanent. Further,
the effect on the iris does not appear to be related to the
duration of drug intake. Although stopping the drug
prior to surgery may have some benefit, IFIS has been
reported to occur up to a year or more after discontinuing the drug.
Therefore, the best strategy for managing IFIS is to perform
cataract surgery before starting Flomax. If your urologist
or primary care physician is contempleting starting you
on Flomax or a similar drug it would be best to use other
methods to manage urinary prostate problems until cataract surgery can be completed in both eyes.
However, many patients are already on Flomax or related
drugs by the time we see them for cataract surgery. Several
strategies have therefore been developed to help reduce the
complications of IFIS during surgery. First, atropine (a potent dilating drop) is prescribed for use in the operative eye
starting about a week before surgery. During the operation
itself, a special solution that can temporaily reverse much
of the floppy iris behavior is injected into the eye. Finally,
in the most severe cases special pupil-stretching techniques
and temporary mechanical iris retractors can be used during surgery to help complete the procedure uneventfully.
Conclusion
Surgical management of cataracts in patients taking Flomax and related drugs remains a challenge. However,
national experience with IFIS is considerable and recent
studies have confirmed that the long-term visual results
of cataract surgery in Flomax patients is on a par with
non-IFIS patients. If you are taking Flomax or a related
drug, please inform your doctor so that we can help assure
an uncomplicated cataract surgical experience. N
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