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ASCRS survey results prompt IFIS education campaign
Prescribing physicians and patients need to be better educated about risks of cataract surgery associated with alpha-blockers, IFIS expert says.
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Despite the fact that it can be anticipated, most surgeons said intraoperative floppy iris syndrome still increases the difficulty and the risks of cataract surgery, according to the results of a recent American Society of Cataract and Refractive Surgery online member survey.
In light of the results, the ASCRS and the American Academy of Ophthalmology are launching a collaborative initiative to better educate prescribing physicians about intraoperative floppy iris syndrome (IFIS) and its association with systemic alpha-blockers such as Flomax (tamsulosin, Boehringer-Ingelheim Pharmaceuticals).
Tamsulosin is the most frequently prescribed medication for benign prostatic hyperplasia (BPH), but other alpha-blockers prescribed for lower urinary tract symptoms include Hytrin (terazosin, Abbott Laboratories), Cardura (doxazosin, Pfizer) and Uroxatral (alfuzosin, Sanofi-Aventis).
IFIS is characterized by poor preoperative pupil dilation, iris billowing and prolapse, and progressive intraoperative miosis. The most common complications of IFIS are iris trauma and posterior capsule rupture, which were reported to occur at a higher rate in IFIS patients by 52% and 23% of survey respondents, respectively.
 David F. Chang |
The ASCRS Cataract Clinical Committee, chaired by David F. Chang, MD, conducted the survey, and the results were published in the Journal of Cataract and Refractive Surgery.
“Many retrospective studies have confirmed a higher cataract complication rate when the surgeon was not forewarned and did not recognize IFIS,” Dr. Chang said in an interview with Ocular Surgery News. “However, the survey suggests that IFIS continues to be a significant surgical risk factor for many surgeons, despite the ability to anticipate IFIS in most cases.”
The survey, conducted in March, comprised 26 multiple-choice questions. A total of 957 ASCRS members completed the survey; 75% of respondents were from the United States.
According to the results, 95% of respondents said tamsulosin made cataract surgery more difficult; 77% reported an increased surgical risk in tamsulosin patients compared with patients who did not use the drug.
IFIS prevention, management
About 21% of respondents said every patient should see an ophthalmologist before starting tamsulosin, another 38% said only those patients with a history of cataracts or decreased vision should, and the remaining 41% felt that this was not necessary.
“Although most felt that patients with cataracts would benefit from an exam, there’s quite a diversity of opinions about this issue,” Dr. Chang said.
“It was interesting that no single preference stood out,” Dr. Chang said. “In fact, approximately one-third of respondents routinely employ more than one strategy for IFIS.”
Effort to educate physicians, patients
There was a strong consensus among survey respondents (91%) that prescribing physicians should be better educated about IFIS. Dr. Chang cited Sallam’s recent survey conducted in the United Kingdom in which 62 out of 64 primary care physicians (97%) were not familiar with IFIS. Approximately four out of five of the surveyed physicians were writing at least five new prescriptions for tamsulosin on a monthly basis, Dr. Chang said.
Dr. Chang also noted that most new prescriptions for alpha-blockers are written by primary care physicians most commonly for BPH and hypertension.
“Urologists tell me that they typically don’t see BPH patients until their urinary symptoms are not responding to pharmacologic treatment,” he said.
For this reason, ASCRS and AAO have developed a joint educational update statement that was circulated by the American College of Physicians and the American Academy of Family Physicians to their 125,000 and 93,000 respective memberships in early July. Online links to the published ASCRS survey paper were provided in these member organizations’ alerts, as well.
“Part of our message is that patients who already have significant cataracts should be educated about IFIS before starting chronic non-emergent treatment with systemic alpha-blockers such as tamsulosin,” he said.
The educational update statement asks prescribing physicians to consider involving the patient’s cataract surgeon.
“The cataract surgeon can not only assess how advanced the cataract is, but also how much risk an alpha-blocker might pose, particularly in light of other comorbidities such as pseudoexfoliation, a brunescent nucleus or prior ocular surgery,” Dr. Chang said. As a result, many patients may be scheduling eye exams or calling for advice before starting alpha-blockers.
“For a patient with significant cataracts, the prospect of IFIS becomes another consideration to weigh in the multifactorial decision of which pharmacologic treatment to initiate for BPH or hypertension,” he said.
“We’re trying to put the burden of evaluating, explaining and discussing cataracts and IFIS on the cataract surgeon,” he said. “I think that this will result in more cataract patients having eye exams prior to starting alpha-blockers, and hopefully, the safety of their eventual cataract surgery will be improved.”
“One of the most telling survey questions was whether ophthalmologists themselves would take tamsulosin if they had BPH and a mildly symptomatic cataract,” Dr. Chang said. Nearly two-thirds of respondents said they would not, opting to have cataract surgery first, to choose a nonspecific alpha-blocker or to avoid alpha-blockers altogether.
“Although we are certainly not advocating specific prescribing recommendations, it makes sense that patients would want to hear about options and alternatives that a majority of ophthalmologists would choose for themselves in the same situation,” he said.
For more information:
- David F. Chang, MD, can be reached at 762 Altos Oaks Drive, Suite 1, Los Altos, CA 94024; 650-948-9123; fax: 650-948-0563; e-mail: dceye@earthlink.net.
References:
- Chang DF, Braga-Mele R, et al. Clinical experience with intraoperative floppy-iris syndrome: Results of the 2008 ASCRS member survey. J Cataract Refract Surg. 2008;34:1201-1209.
- Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin (Flomax). J Cataract Refract Surg. 2005;31:664-673.
- Sallam A. Awareness of IFIS among primary care physicians. J Cataract Refract Surg. 2008;34(6):882.
- Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.