Transcript CATARACT SURGERY IN PATIENTS RECEIVING TERAZOSIN

CATARACT SURGERY IN PATIENTS
RECEIVING TERAZOSIN-GREATER
RISK OF COMPLICATIONS THAN
PREVIOUSLY THOUGHT
JOHN M RAMOCKI M.D.
KRESGE EYE INSTITUTE
WAYNE STATE UNIVERSITY
DETROIT,MICHIGAN
THE AUTHOR HAS NO FINANCIAL INTEREST IN ANYTHING PRESENTED IN THIS POSTER
INTRODUCTION
• ALPHA1-ANTAGONISTS USED IN THE
TREATMENT OF BENIGN PROSTATIC
HYPERTROPHY HAVE BEEN ASSOCIATED WITH
INTRAOPERATIVE FLOPPY-IRIS SYNDROME
(IFIS) –MANIFESTING IN FLUTTERING AND
BILLOWING OF IRIS STROMA,IRIS
mPROLAPSE,AND PROGRESSIVE
CONSTRICTION OF THE PUPIL DURING
CATARACT SURGERY
IFIS
• IFIS WAS FIRST ASSOCIATED WITH FLOMAX
(TAMSULOSIN) BY CHANG AND CAMPBELL BUT
NOW MANY OTHER SYSTEMIC MEDICATIONS ARE
ASSOCIATED WITH IFIS INCLUDING:ALFUZOSIN
(UROXATRAL),DOXAZOSIN (CARDURA),TERAZOSIN
(HYTRIN),PRAZOSIN
(MINIPRESS),MIANSERIN,LABETALOL
(TRANDATE),PHENOXYBENZAMINE,
PHENTOLAMINE,CARVEDILOL (COREG),ERGOT
DERIVATIVES
(ERGOTAMINE,DIHYDROERGOTAMINE),AND
SOME NEUROLEPTIC AGENTS
(CHLORPROMAZINE,HALOPERIDOL).
IFIS AND FLOMAX
• THE ASSOCIATION BETWEEN IFIS AND
FLOMAX(TAMSULOSIN) HAS BEEN WELL
STUDIED SINCE CHANG AND CAMPBELL’S
ORIGINAL ARTICLE AND IN 2005 ASCRS ISSUED
A PHYSICIAN ADVISORY REGARDING THE
ASSOCIATION OF TAMSULOSIN AND IFIS AND
INCREASED COMPLICATION RATES. ALSO IN
2005 THE FDA REQUIRED IFIS TO BE ADDED TO
THE PRECAUTIONS AND ADVERSE REACTIONS
SECTIONS OF THE FLOMAX PACKAGE INSERT.
IFIS AND TERAZOSIN
• THE ASSOCIATION BETWEEN IFIS AND TERAZOSIN
HAS BEEN LESS WELL STUDIED ALTHOUGH
TERAZOSIN (HYTRIN) IS ALSO AN ALPHA1ANTAGONIST USED IN THE TREATMENT OF
BENIGN PROSTATIC HYPERTROPHY BUT IS A LESS
COMMONLY PRESCRIBED MEDICATION
COMPARED TO FLOMAX ( THE MOST PRESCRIBED
DRUG FOR BPH) AND IS LESS HIGHLY SPECIFIC
FOR THE ALPHA1A RECEPTOR AND HAS A HIGHER
INCIDENCE OF POSTURAL HYPOTENSION
PURPOSE
• TERAZOSIN HAS BEEN NOTED TO CAUSE IFIS BUT
HAS BEEN ASSOCIATED WITH ONLY A SLIGHTLY
HIGHER RISK OF COMPLICATIONS FOR PATIENTS
UNDERGOING CATARACT SURGERY (COMPARED
TO TAMSULOSIN WHERE THE RISK IS
SUBSTANTIAL). THE PURPOSE OF THIS STUDY
WAS TO DETERMINE HOW MUCH RISK
TERAZOSIN POSES FOR VITREOUS LOSS AND
PROLONGED O.R. TIME IN PATIENTS
UNDERGOING CATARACT SURGERY.
METHODS
• 648 MALE PATIENT CONSECUTIVE RESIDENT
SUPERVISED CATARACT OPERATIONS FROM 76-2004 TO 9-28-2007 WERE RETROSPECTIVELY
REVIEWED FOR INCIDENCE OF VITREOUS
LOSS,IRIS PROLAPSE,USE OF TERAZOSIN,OR
TAMSULOSIN,LENGTH OF SURGERY,AGE OF
PATIENT,AND NEED FOR IRIS HOOKS.
RESULTS-TERAZOSIN CASES
• 125 OF THE 648 PATIENTS WERE TAKING
TERAZOSIN AT THE TIME OF THEIR CATARACT
SURGERY (19% PREVALENCE) WITH MEAN
AGE OF 75 YEARS. 34 OF THESE 125 PATIENTS
ON TERAZOSIN HAD VITREOUS LOSS DURING
THEIR CATARACT SURGERY (27% INCIDENCE),7
PATIENTS HAD IRIS PROLAPSE (6%
INCIDENCE),AND 3 REQUIRED IRIS HOOKS.
RESULTS-TERAZOSIN CASES
• AVERAGE O.R. TIME ON PATIENTS TAKING
TERAZOSIN WAS 44 MINUTES IN PATIENTS
HAVING NO COMPLICATIONS AND WAS
PROLONGED TO 67 MINUTES WHEN
VITREOUS LOSS OCCURRED.
RESULTS-TAMSULOSIN CASES
• 20 PATIENTS ON TAMSULOSIN HAD A 45%
INCIDENCE OF VITREOUS LOSS WITH AN
AVERAGE O.R. TIME OF 39 MINUTES IN
UNCOMPLICATED CASES AND AN AVERAGE
O.R. TIME OF 80 MINUTES IN CASES OF
VITREOUS LOSS. IRIS PROLAPSE WAS NOTED
IN 3 CASES AND IRIS HOOKS WERE USED IN 1
CASE.
RESULTS-CASES WITHOUT TERAZOSIN
OR TAMSULOSIN
• 14% INCIDENCE OF VITREOUS LOSS WITH
AVERAGE O.R. TIME OF 76 MINUTES IN CASES
WITH VITREOUS LOSS AND AVERAGE O.R.
TIME OF 44 MINUTES IN CASES WITHOUT
VITREOUS LOSS.
CONCLUSIONS
• USING TERAZOSIN PRIOR TO CATARACT
SURGERY POSED A HIGHER RISK FOR
VITREOUS LOSS AND OTHER COMPLICATIONS
THAN WHAT HAS PREVIOUSLY BEEN
REPORTED. THE RISK OF VITREOUS LOSS WAS
HIGHER THAN AMONG PATIENTS NOT ON
TERAZOSIN (27% VS 14%) BUT LOWER THAN
TAMSULOSIN (45%).
CONCLUSIONS
• SURGEON BEWARE ! THE USE OF
MEDICATION FOR BPH IS ALSO INCREASING IN
THE POPULATION. IN THIS STUDY THE
PREVALENCE OF TERAZOSIN INCREASED OVER
THE PAST 3 YEARS FROM 13% TO 18% TO 20%.
REFERENCES
• CHANG DF,CAMPBELL JR.INTRAOPERATIVE FLOPPY IRIS
SYNDROME ASSOCIATED WITH TAMSULOSIN.J CATARACT
REFRACT SURG 2005;31:664-673
• SCHWINN DA,AFSHARI NA.ALPHA1-ADRENERGIC
ANTAGONISTS AND FLOPPY IRIS SYNDROME:TIP OF THE
ICEBERG?[EDITORIAL] OPHTHALMOLOGY 2005;112:20592060
• OSHER RH.ASSOCIATION BETWEEN IFIS AND FLOMAX.J
CATARACT REFRACT SURG 2006;32:547
• CHANG DF,OSHER RH,ET AL.PROSPECTIVE MULTICENTER
EVALUATION OF CATARACT SURGERY IN PATIENTS TAKING
TAMSULOSIN (FLOMAX).OPHTHALMOLOGY 2007;114:957-964