Eyeworld

I WHAT YOUR PATIENT IS TAKING AND ITS EFFECT ON THE EYE N FOCUS 58 | EYEWORLD | JANUARY/FEBRUARY 2020 by Liz Hillman Editorial Co-Director insights on the systemic medications that could be causing or exacerbating dry eye. "Systemic comorbidities and systemic medi- cations are a huge part of what I'm looking for, particularly as they relate to ocular surface disease," Dr. Yeu said. For Dr. Singleton, it all starts with taking a good history. "A good medical history, even if the patients don't know all of their systemic medications, will clue you in to medications that T he pills your patients are taking might be causing some of the dry eye symptoms they're complaining about as they sit in your exam chair. But just what medications should you be asking about, what could be cluing you in on their medical histories, and what should you do about medication-related dryness? Elizabeth Yeu, MD, Chasidy Singleton, MD, and William Trattler, MD, gave EyeWorld some Systemic medications and dry eye At a glance • Oral, systemic medications can have a drying effect on the ocular surface. • These include diuretics, some allergy medications, antide- pressants, antipsychotics, retinoids, and more. • Taking a careful history and looking for conditions that might merit a patient taking these medications can help inform whether they are a factor in dry eye conditions. • In some cases, systemic medications can be substitut- ed for others that won't have the ocular drying effect, but in other cases the medication must be continued and the dry eye condition treated appropri- ately by the ophthalmologist. continued on page 59 prevention and postop pain management. It currently has extended pass-through status, and in 2019 CMS established a permanent J code. Intraop management Medical intervention can be enough to deal with IFIS. "Pharmacologic management of IFIS has been satisfactory without typically resorting to more expensive devices," Dr. Myers said. However, "[i]f the pupil size is inadequate to complete a capsulorhexis after the intracam- eral dilation agents and OVD are instilled, then I proceed to using either hooks or less com- monly rings," he added. "The decision is based on the pupil size and not the potential for IFIS developing. It is better to place hooks or rings prior to capsulorhexis to avoid damage to the capsule." "Iris retractors are my choice for patients where the pupil dilates poorly and the patient is on alpha blockers," Dr. Safran said. "They are safe and work extremely well." Surgeons should use iris dilating devices with caution. "Any time you are using a device to manipulate the iris, there is a risk of causing an irregular pupil, iridodialysis, or bleeding," Dr. Lee said. "However, these are rare problems, and most cataract surgeons are very familiar with using mechanical dilation." Although other devices such as the Mal- yugin ring work well, Dr. Lee prefers reusable hooks because they allow the surgeon to stretch the iris out more to get it out of the way, which IFIS irises tolerate well. Hooks can be left in later to verify toric IOL position at the end of the case and take up less space in a shallow chamber. Nevertheless, he will prefer a ring in certain cases, such as small lid fissures, uncoop- erative patients, or keratoconus. Usual and unusual suspects Among the alpha-1 adrenergic antagonists, "tamsulosin and silodosin are the two most likely to cause significant IFIS," probably due to their being selective alpha blockers, Dr. Lee said. "It's important to remember that tamsu- losin is also in a combination with dutasteride called Jalyn and that women are now taking tamsulosin more frequently." However, it's just as important to remem- ber that alpha blockers aren't the only possible causes of IFIS. "Tamsulosin is the agent most associated with IFIS, but other causes are any- thing that might affect the iris dilator muscle, including other alpha blockers, diabetes, and certain viral infections," Dr. Myers said. "For this reason, I use intracameral dilation with phenylephrine and lidocaine on every patient, regardless of their use of alpha blockers sys- temically." Dr. Safran also added that over-the- counter saw palmetto has been shown to cause IFIS. This is important to ask for in men (and some women) who might be using it and not mention it. continued from page 56

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