EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/387844
EW FEATURE 78 Complex cataract cases October 2014 Alpha-blockers and cataract surgery Alpha-blockers—and tamsulosin in particular—are well-known caus- es of IFIS. None of the physicians recommended that patients stop their medication use before cataract surgery simply because the patient "can run into bladder issues during the case if they're on tamsulosin for benign prostatic hyperplasia," Dr. Summerfield said. "Discontinuing the medication could make the condition worse, and it's not going to help with the floppy iris. Because there are numerous drugs that can treat prostate disor- ders, Dr. Summerfield has broadened his questioning to ask if patients "have any prostate hypertrophy or if they have any bladder issues at all, for women." Dr. Gupta cited a case recent- ly where a woman on finasteride and doxazosin developed IFIS; although these drugs are often used as prostate medications, the patient was using it to treat alopecia and hypertension. Some blood pres- sure medications are in the same alpha-blocker family as tamsulosin, and Dr. Gupta expects more women will develop IFIS than may be expected. "By asking open-ended ques- tions about any drug use for prostate issues, you're able to discover that patients may have a history of using tamsulosin or related medications in the past. Even saw palmetto, using them in patients with scarring conditions of the pupil." Centration is not a considerable factor as long as the capsule is intact, she said. "The IOL itself will still work from an optic perspective whether the pupil is widely opened, whether it's fixed at a particular diamete , or whether it's completely normal," she said, but cautioned that managing patient expectations is essential. After implanting a toric lens in these patients, Dr. Gupta removes the OVD from behind the lens and rotates it "to within about 20–30 degrees of where my final axis of placement is going to be," removes more OVD, and rotates the lens a bit closer to the final axis. "When the lens is within 5 degrees, I will take out the Malyugin ring and fine-tune the IOL plac - ment," she said. "The pupil will often stay a little bit stretched after you take the Malyugin ring out." She advised retaining some of the OVD in the chamber when remov- ing the ring "so there's less damage to the endothelium." But if the pupil does come down or if visualization is difficult, she takes a Kuglen hook (Katena, Denville, N.J.) and "essentially tents the iris far enough into the periphery so that I can see the exact alignment of the lens." She puts "some gentle downward pressure on the lens so it doesn't rotate" as she removes the remaining OVD. Cataract surgery continued from page 76 Couple small pupils with patients who want toric lenses and "it's important to have a low threshold to use a pupillary expansion device, especially where you need to see the marks for alignment." –Preeya K. Gupta, MD with enough chronic use, can cause significant IFIS," D . Green said. "Tamsulosin is the worst offender, but alfuzosin can wreak havoc as well." Dr. Gupta is particularly wary when patients have light-colored irises and use alpha-blockers. "In these cases, I always use 'Shugarcaine' (lidocaine/epinephrine solution) to manage the potential complications better," she said. Dr. Green has "been using intracameral epinephrine for all known cases with a history of tamsulosin use, even if that use was several years prior to the cataract surgery. I think it's very important to identify these cases." If epinephrine is insufficient, she'll move to using iris retractors. Hidden lens fragments Retained lens fragments "can be very easily overlooked. Surgeons can be distracted by the small pupil and lens removal; our train of thought concentrates on what we perceive to be the most difficult aspect of the surgery," Dr. Gupta said. Spend extra time vacuuming with a push/pull technique and have a high suspicion for hiding fragments, she recom- mended. The key, Dr. Green said, "is observing the anterior chamber with the final irrigation and aspir - tion (I/A) after implantation of the IOL. Carefully irrigate around the anterior chamber; I certainly take more time and more effort than I normally would in a standard case." Dr. Summerfield advised surgeons to "clean up as you go along," even if surgeons are using a femtosecond laser for some aspects of the surgery. "Check the wound, hydrate through the wound at the end of the case, and double check retained fragments aren't there," he said. If he's concerned about lens frag- ments, he'll "take a cannula with just balanced salt solution and flush through the main incision, let it all circulate through the eye, and 'whirlpool' in there to flush out anything that may be stuck." Dr. Green will "intentionally use Miochol-E [acetylcholine, Novartis, Basel, Switzerland] to gently irrigate small fragments around into the angle to aid me in flushing out any additional nuclear fragments." "Look at the actual configur - tion of the iris," Dr. Gupta said. "If you use a chop technique where you're fractionating the lens into a lot of small pieces or if the cataract is dense, sometimes the phaco machine will shatter the small-to- medium-sized pieces. I have a low threshold to look under the iris, while my irrigation handpiece is in the eye, to make sure nothing's trapped. By tenting the iris with the irrigation handpiece, while you have the irrigation on but not the aspiration, you can use the I/A tip to lift up the iris enough to clear a fragment. That will swirl the fluid around in the anterior chamber to flush that space where a lens fra - ment could potentially be retained." She's particularly careful with any cataract grade 3 or higher. "Irrigating a little longer than normal will help you discover those hiding places," Dr. Green said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Green: largreen@lifebridgehealth.org Gupta: preeya.gupta@duke.edu Summerfield michaelsummerfield@gmail.co Chicago Fun Fact The Chicagoland area contains nearly 10 million people in 3 states—Illinois, Wisconsin, and Indiana—and is the 22nd largest metropolitan area in the world. www.cityofchicago.org