Physician groups urge patients to disclose Flomax use to cataract surgeons

Ophthalmologists can use modified surgical techniques to overcome the adverse effects of alpha-blocking medications on pupil dilation during cataract surgery, but first they must be aware of the patient's use of such drugs. Three specialty medical societies recently joined together to urge patients to tell cataract surgeons if they are taking one of these drugs to treat prostate enlargement.

Flomax (tamulosin, Boehringer-Ingelheim) is the most widely used of the class of drugs called alpha-blockers (also including terazosin, doxazosin and alfuzosin), which are used to treat benign prostatic hyperplasia. In 2005, David F. Chang, MD, and John R. Campbell, MD, reported that the drug could cause sudden iris constrictions during cataract surgery, despite pharmacologic pupil dilation. The identification of this condition, termed intraoperative floppy iris syndrome (IFIS), spurred the Food and Drug Administration to require addition of a warning to Flomax's label information.

In a conference call for media on August 22, representatives from the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology and the American Urological Association urged doctors to continue prescribing Flomax but stressed the need for awareness of the issue among patients.

"Flomax is an excellent prostate medication," Dr. Chang said during the call. "However, the key is for patients to inform their ophthalmologist when they are taking this or any prostate drugs prior to eye surgery. The information ... is critical, and it can make the difference between having a good outcome with cataract surgery or a high risk of complications."

Dr. Chang noted that patients might not normally think to tell an eye surgeon about a medication they are taking for a prostate condition. The joint statement by the AAO, ASCRS and AUA is meant to heighten patient awareness of the need to disclose use of alpha-blockers before cataract surgery.

Dr. Chang chaired the ASCRS Flomax Task Force, which developed recommendations for cataract surgery in patients taking Flomax or other alpha-blocking agents. The recommendations include intraoperative use of iris hooks or expansion rings, intraoperative use of epinephrine and administration of atropine three times daily for 2 days preop.

In a study, Dr. Chang found that using such modifications in surgery yielded rates of success and of complications comparable to those in non-Flomax-treated patients. The approaches require extensive preparation, however, underscoring the importance of preoperative knowledge of Flomax use, Dr. Chang said.

While Flomax is the most popular of the alpha-blocking drugs, any of them can potentially cause IFIS. Other drugs in this class include Hytrin (terazosin, Abbott), Cardura (doxazosin, Pfizer) and Uroxatral (alfuzosin, sanofi-aventis). Saw palmetto, an herbal supplement used as a remedy for prostate enlargement, can also produce symptoms like IFIS, said Samuel Masket, MD, president of ASCRS, during the conference call.

Patients may still be at risk for IFIS up to 5 years after discontinuing use of an alpha-blocker, Dr. Chang said. Women who take alpha-blockers to treat lower urinary tract symptoms may also be at risk, said Lawrence Ross, MD, president of the AUA, during the conference call.