Eyeworld

16 September 2018 EW NEWS & OPINION Chief medical editor's corner of the world by Jack Parker, MD, PhD, and Christina Pierpaoli Parker, MA courses compared to patients being treated chronically for prostatic hyperplasia. 11 Even so, it would no doubt be interesting to read reports from cataract surgery in this cohort of pa- tients (and considering the psychiat- ric prescribing practices of the past 2 decades, ample opportunity to con- duct such a study might be found). There is at least some (if less than ideal) awareness of the ophthalmic consequences of tamsulosin among urologists, 12 and it might be useful if study data were available to provide psychiatrists and sleep medicine doctors with a similar suggestion for caution. Even without such evidenced- based recommendations, cataract surgeons may be tempted to breathe a sigh of relief that a potential IFIS-inducer has been publicly exposed. But not so fast—that controversial paper specifically admits that prazosin may still be useful as a sleep aid and nightmare suppressant, at least for a subset of patients. In fact, in an interview, the first author stated bluntly about As plausible as that sounds, the published successes with prazosin have frequently involved eyebrow- raisingly high dosages—sometimes up to 45 mg daily. 7,8 Compare this to the daily indicated dosage for a "cousin" alpha-1 blocker, Flomax (tamsulosin, Boehringer Ingelheim Pharmaceuticals, Ridgefield, Con- necticut), which is conventionally recommended at 0.4 mg daily. This brings us to the punchline: There seems to be a hidden popu- lation of psychiatric patients being prescribed a suspect IFIS-producing drug at up to 100 times the standard Flomax dosage. We had no idea. Does that mean that there's a group of "super Flomax" users out there? We don't know. Almost the whole of the literature links IFIS with tamsulosin, specifically, despite the common mechanism of action, 9 and there's only one publication implicating prazosin by name. 10 Further, IFIS severity appears at least partially correlated with duration of medication use, and conceivably, pa- tients using prazosin as a psychiatric adjunct may receive abbreviated E arlier this year, a bomb- shell study hit the pages of the New England Journal of Medicine—a multicenter, randomized, double-blind, placebo-controlled trial demonstrat- ing prazosin's ineffectiveness to treat post-traumatic stress disorder (PTSD) in a sample of military veterans. 1 That report ignited a firestorm of controversy, with physicians and psychologists alike jumping into the fray to debate, including in pages of some popular outlets like Scientific American. 2–4 But for us, the report provoked a different reaction—a bizarre sense of confusion. Prazosin, the weak an- ti-hypertensive medication, is being prescribed for PTSD? Apparently, yes. Since at least the year 2000, the U.S. Department of Veterans Affairs (VA) has used this alpha-1 adrenergic blocking agent to treat trauma-in- duced nightmares, in some cases as first-line medical therapy. 5,6 The medication suppresses noradrena- line's nighttime access to the brain, thereby protecting rapid eye move- ment (i.e., dreaming) sleep from unwanted activation. 5,6 Flomax has a big brother, and the psychiatrists have him I ntraoperative floppy iris syndrome (IFIS) is one of the most common causes of pupillary constriction during cataract surgery and is associated with an increased risk of intraoperative complications. The syndrome was first described by Chang and Campbell in the Journal of Cataract and Refractive Surgery in 2005 and was originally associated with the systemic use of tamsulosin. Subsequently, IFIS has been associated with other alpha-1 adrenergic receptor antagonists and the homeopathic saw palmetto. The association of IFIS with the use of prazosin for the treatment of post-traumatic stress disorder adds a new risk factor that ophthalmologists should be aware of. Eric Donnenfeld, MD, chief medical editor

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