Eyeworld

EW FEATURE 102 Challenging and complicated cataract surgery • October 2016 AT A GLANCE • Patients who have used tamsulosin or similar alpha-1 antagonists may experience IFIS during cataract surgery. • Ask patients preoperatively about their use of tamsulosin or similar medications, as well as the herb saw palmetto. • Special dilating mixes can assist with dilation in eyes at risk for IFIS. • Use devices like the Malyugin ring or iris hooks as necessary. by Vanessa Caceres EyeWorld Contributing Writer Eye Consultants, Minneapolis. "One of the features of IFIS is that it can be a wolf in sheep's clothing. That is, you may start the case with a perfectly normal-sized pupil or close to it. However, during the case, it becomes apparent that the iris tone is reduced, and there's a significant tendency for iris prolapse. Once that process begins, the pupil often becomes less dilated and quite often much smaller than when the case first started." With small pupils caused by other conditions, surgeons know in advance that hooks or rings will be needed. In a patient who has used tamsulosin or other similar medi- cations, "you may need to change the plan and insert pupil expanding devices on the fly, after the phaco has started," Dr. Samuelson said. Surgery in these eyes can take longer and be more challenging, said Michael Greenwood, MD, Vance Thompson Vision, Fargo, North Dakota. The cascade effects from IFIS, including the increased risk for iris damage, can lead to awful outcomes, said Garry Condon, MD, chair, De- partment of Ophthalmology, Allegh- eny General Hospital, Pittsburgh. Tamsulosin is the most widely prescribed alpha-1 antagonist for benign prostate hyperplasia in North Cataract surgeons advise careful step-by-step evaluation for fewer complications C ataract surgeons must con- tinue to effectively tackle the risk for intraoperative floppy iris syndrome (IFIS) and the small pupils that can accompany it. "IFIS related to the systemic use of tamsulosin presents some unique pupil-related management prob- lems for the phaco surgeon," said Thomas Samuelson, MD, attending surgeon and co-founder, Minnesota Managing IFIS and small pupils Monthly Pulse Challenging and complicated cataract surgery T he topic of this Monthly Pulse survey was "Challenging and complicated cataract surgery." We asked what you do when the capsule breaks and vitreous is lost, and the majority of re- spondents to our survey said, "I perform a bimanual anterior vitrectomy (splitting irrigation and aspiration) and make new incisions." In eyes that have had a vitrectomy or injection due to retinal issues, the majority of respondents said all of the above: timing of the cataract formation is important (could mean lens was touched); patients should be given a guarded prognosis due to retinal pathology; and cataract surgeons should look for zonular integrity or posterior capsular opacities. When dealing with IFIS or small pupils, the majority use all of the above depending on the case: pharmaceutical adjuvants such as Shugarcaine or phenylephrine only; pupil expanding devices such as Malyugin ring or iris hooks; and viscoadaptive agents. Finally, we asked what you do if the capsule breaks and there is no posterior capsular support. "Put a three-piece IOL in the sulcus" was the most popular answer. America, but there are other similar drugs that patients may use. Surgeons advise assessing for possible risks of IFIS early on, in the preop period. Dr. Condon will ask patients if they have had any treatment for a prostate condition. "Simply asking if they are taking tamsulosin is inade- quate in terms of getting the full sto- ry," he said, because there are other drugs that cause the same effect. He will also ask female patients if they have used drugs from the same class. In addition to prescription medications, over-the-counter herbs such as saw palmetto can cause IFIS issues, Dr. Condon said. Dr. Samuelson makes sure to let patients who have exfoliation-relat- ed glaucoma or who use tamsulosin know that they have a greater risk for surgical complications, albeit a small risk. Before insertion of a Malyugin ring

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