Mitchell A Jackson MD

Lake Villa IL USA [email protected]

Relevant financial disclosure: Member Bausch + Lomb speaker’s bureau

    First described by Chang and Campbell in 2005 1 Excessive billowing/floppiness of mid-peripheral iris may lead to:  Iris prolapse at main and/or side incisions  Progressive miosis  Poor preoperative pupil dilation Complication rate overall is 77% 2   Posterior capsule rupture/vitreous loss (23%) Iris trauma (52%) 49% of ophthalmologists would have their own cataract removed first-even at early stage-prior to starting tamulosin (1) Chang D, Campbell J. JCRS 2005;31:664-67. (2) Chang D et al. J Cataract Refract Surg 2008;34:1201-1209.

 Well established with systemic use of alpha-1 adrenergic antagonists  Tamsulosin (Flomax), Silodosin (Rapaflo) – BPH tx  Can even occur with nonspecific alpha-1 antagonists  Terazosin (Hytrin), Doxazosin (Cardura), Alfuzosin (Uroxatral)  Alpha-1a receptor subtype predominates in prostate and iris dilator muscle  Stopping treatment preop is unpredictable and IFIS has been reported for up to several years after stopping tamulosin

 Masket 1  Preoperative atropine 1% drops tid for 1-2 days   Intraoperative 1:2500 epinephrine hydrochloride Potential acute urinary retention so don’t stop tamulosin  Packard 2 and Shugar 3  Intracameral phenylephrine/epinephrine preservative-free solutions in appropriate diluted mixture  Bimanual microincisional cataract surgery with its smaller, tighter incisions plus keeping irrigation inflow anterior to the iris may also lessen IFIS 4 (1) Masket S, Belani S. JCRS 2007;33:580-582.

(3) Shugar J. JCRS 2006;32:1074-1075.

(2) Gurbaxani A, Packard R. Eye 2007;21:331-332.

(4) Chang D, Campbell J. JCRS 2005;31:664-67.

   OVD “donut” in anterior chamber1  Cohesive OVD (Healon 5) peripherally and dispersive OVD (Viscoat) centrally  Dispersive OVD resists aspiration, delaying evacuation of cohesive OVD over the iris Mechanical expansion devices  Most are bulky and difficult to position in small pupils (<4 mm) or shallow anterior chambers  Newer Malyugin rings limited to 2.2 mm incision size Iris Retractors/Hooks  Subincisional (main and side) hooks (4) retract iris downward and out of path of phaco tip and 2nd instrument (Diamond configuration)2  Subincisional hook (1) at main incision with adequately dilated pupil3 (1) Chang D et al. Ophthalmology. 2007;114:957-64.

(3) Tint et al JCRS 2009;35:1849-1852.

(2) Oetting T, Omphrov L. JCRS 2002;28:596-598.

 Simple and efficient  Combine microincision cataract surgery (MICS) through 1.8 mm incision with:  Single iris hook if pupil dilation is good  Diamond 4-hook technique if pupil dilation is poor  Stellaris fluidics provides high level of chamber stability  Tight seal of MICS seems to minimize iris prolapse toward phaco incision

 Retrospective review of 20 eyes of patients who were prescribed tamulosin  Good pupil dilation  Planned uncomplicated 1.8 mm coaxial MICS with Stellaris system  Topical and intracameral anesthesia only

 No complications  No posterior capsular/zonular compromise or vitreous loss  No iris trauma or pigmentation changes  Phaco times approached those of non tamulosin cases reported in Stellaris system evaluation

Mean 1.8mm Coaxial-MICS 1.8mm Biaxial-MICS 2.8mm Standard Cataract Surgery Effective Phaco Time (EPT) 4.6 sec 2.8 sec 5.1 sec Power 12.5% 10.8% 13.0% Data from Bausch + Lomb

 Stellaris 1.8 mm coaxial MICS and single subincisional iris retractor maintains stable anterior chamber with minimal to no iris prolapse  With poorly dilated pupil, use 4 hooks in diamond configuration  Phaco efficiency and times essentially unchanged with tamulosin cases acting like and approaching safety rates of non-tamulosin cases