Eyeworld

EW CATARACT 82 April 2017 Research highlight by Maxine Lipner EyeWorld Senior Contributing Writer To experience such pressure spikes, such patients don't need to currently use tamsulosin; they only need to have been on this medi- cation at one point, according to Mr. Bonnell. Those included in the study had exposure to tamsulosin within the past 6 months, he notes. "It's known to stay in the body," Mr. Bonnell said. Dr. Davidson concurs. "Even if you were on it for a week 2 years before your surgery event, that 1 week of tamsulosin can have an ef- fect," he said. "Unfortunately, we've seen cases where a couple of days or a week of exposure years before cataract surgery, will still result in this floppy iris syndrome, so, there's no real benefit to stopping it prior to cataract surgery." He hopes that practitioners come away from the study with a heightened awareness of issues with tamsulosin. "As far as the pressure, properly counsel the patients, and for those who are at high risk or who already have compromised optic nerves, it may be worthwhile to pretreat them with pressure-lower- ing agents to try and minimize any potential damage postoperatively," Dr. Davidson said, adding that being as meticulous as possible is also para- mount. Going forward, Dr. Davidson would like see if results improve based on the lessons of the study. "As a group, we have about 10 cata- ract surgeons, and they're all aware of the study," he said. "It would be nice to go back a year or two from now and see if we've made a differ- ence in our practice as far as being able to have fewer pressure spikes." EW Reference 1. Bonnell LN, et al. One-day postoperative intraocular pressure spikes after phacoemul- sification cataract surgery in patients taking tamsulosin. J Cataract Refract Surg. 2016;42:1753–8. Editors' note: Neither Dr. Davidson nor Mr. Bonnell have any financial interests related to their comments. Contact information Bonnell: levi.bonnell@ucdenver.edu Davidson: Richard.davidson@ucdenver.edu said. "Now the iris is flopping in the breeze and tends to want to shoot out towards the incision." As a re- sult, while many practitioners try to remove as much of the ophthalmic viscosurgical device from the surgery as possible, most are probably not spending as much time in the eye doing so as in a case involving a stable dilated iris, he explained. Avoiding pressure spikes Understanding this may enable prac- titioners to sidestep such complica- tions. "Knowing that there is a larger percentage of patients getting these pressure spikes, I hope that most of us will make the attempt to spend more time inside the eye, even with the floppy iris, to try to remove as much viscoelastic as possible," Dr. Davidson said, adding that for those with glaucoma, it may be worth treating them prophylactically at the end of the case with pressure-low- ering agents knowing that there's chance that they might have a spike. Also, glaucoma patients who have taken tamsulosin should be properly counseled about the possibility that they could have a pressure spike, so that they are aware that there is an additional risk of the surgery, he said. Looking back, investigators found that there was indeed a correlation between postoperative pressure and tamsulosin usage. "Patients who were on tamsulosin were 2.8 times more likely to have a pressure spike of greater than 10 mm Hg from their baseline measurement and were almost five times more likely to have a pressure spike over 30 after adjusting for other signifi- cant covariants," Mr. Bonnell said. The results did not come as a great surprise to investigators, Dr. Davidson said. "I think we were curi- ous to see if there really was going to be a correlation," he said. "We had all spoken about this anecdotally for a while, and I can't say that we were happy to see that there was a pressure spike, but I think that it's actually very helpful to know the data." Investigators theorize that the pressure spikes here are actually linked to the floppiness of the iris that occurs due to the tamsulosin. "In cases like this, even when we put in a Malyugin ring to stabilize the iris during the surgery, once the implant is in, we remove the ring, and so we still have to remove the viscoelastic. As we're removing the viscoelastic, we now have nothing stabilizing the iris," Dr. Davidson Study indicates patients who had previously taken tamsulosin were more prone to pressure spikes W hile most patients undergo cataract sur- gery without pressure spikes postoperative- ly, for one group of patients, the risk may be higher than most, according to Richard S. Davidson, MD, professor of ophthalmology and vice chair for quality and clinical affairs, Univer- sity of Colorado, Denver School of Medicine, Denver. Results published in the December 2016 issue of the Journal of Cataract and Refractive Surgery indicate that those who have taken tamsulosin (Flomax, Boeh- ringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut) at some point were more prone to pressure spikes following cataract surgery than those who had not. 1 The fact is that tamsulosin, which is commonly prescribed for prostate issues, is something that a swath of male patients have used. "I would say between 4 and 10 percent of our male patients are probably either on tamsulosin or some form of alpha blocker," Dr. Davidson said. Investigating tamsulosin usage Investigators were spurred to exam- ine what might be going on with those who had used tamsulosin by some cases in Dr. Davidson's group practice. In these cases, pressure spikes in the 1-day postoperative period were noticed. This prompted curiosity as to whether there was a correlation to the fact that these patients were on tamsulosin or not, Dr. Davidson noted. The protocol was a retrospective one, according to fellow investiga- tor, Levi N. Bonnell, MPH, Uni- versity of Colorado, Denver School of Medicine. "We have a cataract registry, and basically we manually reviewed the medical charts retro- spectively," Mr. Bonnell said, adding that investigators had almost 2 years of complete data from which to draw. Tamsulosin usage and cataract surgery Iris damage during phaco in a case of floppy iris syndrome Source: Daljit Singh, MD

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