Ophthalmology groups educate PCPs on link between alpha-blockers, IFIS

Issue: August 2008

ByMatt Hasson

The American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology launched a collaborative initiative to better educate prescribing doctors about intraoperative floppy iris syndrome (IFIS) – which can occur during cataract surgery – and its association with systemic alpha-blockers.

ASCRS and AAO 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.

Survey results prompt action

This effort is a response to the results of a recent ASCRS online member survey indicating that despite the fact that it can be anticipated, most surgeons said IFIS still increases the difficulty and the risks of cataract surgery. 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.

“We have also asked the American Academy of Optometry, the American Optometric Association and Vision Service Plan to share the survey and the joint educational update statement with their members,” Dr. Chang said. “Optometrists, in turn, may wish to discuss the issues surrounding IFIS with the cataract surgeons to whom they refer.”

A total of 957 ASCRS members completed the survey, which was conducted in March. According to the educational update statement to the prescribing physicians, 59% of ophthalmologists who responded to the survey “would recommend an ophthalmic evaluation for patients with a history of cataracts or decreased vision prior to initiating treatment with tamsulosin.”

Flomax (tamsulosin, Boehringer-Ingelheim) is the most frequently prescribed medication for benign prostatic hyperplasia (BPH). Other alpha-blockers prescribed for lower urinary tract symptoms include Hytrin (terazosin, Abbott Laboratories), Cardura (doxazosin, Pfizer) and Uroxatral (alfuzosin, Sanofi-Aventis).

The survey results showed that 95% of respondents said tamsulosin made cataract surgery more difficult, and 77% reported an increased surgical risk in tamsulosin patients compared with patients who did not use the drug.

Dr. Chang, who said he and John Campbell, MD, first reported IFIS in 2005, noted that most new prescriptions for alpha-blockers are written by primary care physicians most commonly for BPH and hypertension.

“Part of our message is that patients who already have significant cataracts should be educated about IFIS before starting chronic nonemergent treatment with systemic alpha-blockers such as tamsulosin,” Dr. Chang explained.

According to the statement, “In a patient with a known diagnosis of cataract, prescribing physicians may wish to consider involving the patient’s cataract surgeon prior to initiating nonemergent, chronic tamsulosin or alpha-blocker treatment.”

Dr. Chang said, “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.” As a result, many patients may be scheduling eye exams or calling their optometrist or ophthalmologist for advice before starting alpha-blockers, such as Flomax.

Complications of IFIS

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.

“Many retrospective studies have confirmed a higher cataract complication rate when the surgeon was not forewarned and did not recognize IFIS,” Dr. Chang said. “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.”

Diverse opinions

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.

“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 said they would not, opting either to have cataract surgery first, choosing a nonselective alpha blocker or avoiding alpha blocking 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 a patient with significant cataracts, the prospect of IFIS becomes another consideration to weigh in the multifactoral decision of which pharmacologic treatment to initiate for BPH or hypertension,” Dr. Chang continued. This educational effort will result in more cataract patients having eye exams prior to starting alpha-blockers and, it is hoped, the safety of their eventual cataract surgery will be improved.”

For more information:

David F. Chang, MD, is a clinical professor at the University of California, San Francisco, and 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:

American Academy of Family Physicians. Intraoperative floppy iris syndrome (IFIS) associated with systemic alpha-1 blockers: ASCRS and AAO educational update statement. www.aafp.org/online/en/home/publications/news/news-now/clinical-care-research/20080702alpha-cataract.html. Published July 2, 2008. Accessed July 14, 2008.

Chang DF, Braga-Mele R, Mamalis N, 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.