CASOS CLÍNICOS

Treatment with tamsulosin. Should the cataract be operated before?

Tratamiento con Tamsulosina. ¿Debe operarse la catarata?

Julio González Martín-Moro¹ y Víctor Martínez Silva².

¹Servicio de Oftalmología. Hospital de la Princesa. Madrid.
²Servicio de Urología. Hospital Doce de Octubre. Madrid. España.

Correspondence

SUMMARY

Objective: Recently, intraoperative floppy-iris syndrome (IFIS) has been related to tamsulosin treatment. This review evaluates the epidemiological evidence of the association of tamsulosin with IFIS and the necessity of a prior ophthalmologic examination in this group of patients.
Method: Systematic review of the literature.
Results: Since 2005, when the syndrome was described, some studies have confirmed this association. Tamsulosin is the most clearly involved drug. No prospective studies have been published, but some authors consider that the syndrome affects, at least, half of the patients receiving this drug. No medical treatment has demonstrated its usefulness in the prevention of this syndrome.
Conclusion: Considering the high prevalence of this syndrome, all the patients who are going to start this treatment should receive previous ophthalmologic examination, to evaluate the convenience of performing early cataract surgery in order to avoid intraoperative complications.

Key words: Tamsulosin. iFIS intraoperative floppy-iris síndrome. Cataract surgery.

RESUMEN

Objetivo: Recientemente se ha relacionado el síndrome del iris flácido (intraoperative floppy-iris syndrome o IFIS) con el consumo de tamsulosina A través de esta revisión pretendemos evaluar esta asociación epidemiológica, así como la necesidad de que este grupo de pacientes sea sometido a un examen oftalmológico previo al inicio del tratamiento.
Método: Revisión crítica de la literatura relacionada.
Resultado: Desde que en el año 2005 se describiera por primera vez este síndrome, varios estudios han confirmado esta asociación. El fármaco más claramente asociado es la tamsulosina, y aunque no se han publicado estudios prospectivos se considera que afecta, al menos, a la mitad de los pacientes que reciben este tratamiento. No existe ningún tratamiento médico que haya demostrado ser eficaz en su prevención.
Conclusiones: Dada la alta prevalencia de este síndrome, sería recomendable que todos los pacientes que vayan a iniciar este tratamiento sean valorados previamente por el oftalmólogo con la finalidad de que en caso de considerarse necesario se lleve a cabo la cirugía de la catarata de forma precoz, para evitar de este modo posibles complicaciones quirúrgicas.

Palabras clave: Tamsulosina. Síndrome del iris flácido. Cirugía de catarata.

In 2005 Chang made the first description of the intraoperative floppy-iris syn-drome (IFIS) and related this surgical complication to tamsulosin intake. Since then, many publications have confirmed this association. The floppy-iris syn-drome is characterized by fluttering and billowing of the iris stroma, tendency of the iris to prolapse through the corneal incisions and narrowing of the pupil during surgery.

It has been estimated that this syndrome appears in al least one half of the patients that have been under tamsulosin treatment. Some papers have related this syndrome with other drugs, but most of the publications relate IFIS with alfa 1-antagonists intake.

From a physiopathologic point of view, it is believed that continuous inhibition of the pupil dilator fibers produces atrophy of the muscle. The consequence is the bad initial mydriasis, which is lost during surgery. The low tone of the dilator muscle allows the iris to prolapse through the incisions during the procedure. Finally the surgical time and the probablility of complications is significally increased. In some cases the surgeon is forced to use iris hooks or other "gadgets" to maintain a reasonable mydriasis.

Some authors advocate to premedicate the patient with atropine or to inject epinephrine in the anterior chamber during the surgery. Nevertheless there is no agreement in the effectiveness of these measures.

That's why we consider that urology specialists should be aware of the existence of this syndrome, and all the patients should be referred to the ophthalmologist before starting tamsulosin treatment in order to perform an earlier and safer surgery.

Correspondence:
Julio González Martín-Moro
Servicio de Oftalmología
Hospital de la Princesa
Diego de León, 62
28006 Madrid. (España).
juliogmm@yahoo.es

Accepted for publication: 13^th december, 2007.

References and recomended readings (*of special interest, **of outstanding interest)

**1 CHANG, D.F.; CAMPBELL, J.R.: "Intraoperative floppy iris syndrome associated with tamsulosin". J. Cataract. Refract. Surg., 31: 664, 2005.        [ Links ]

2. CHADHA, V.; BOROOAH, S.; TEY, A. y cols.: "Floppy iris behaviour during cataract surgery: Associations and variations". Br. J. Ophthalmol., 91: 40, 2007.        [ Links ]

**3. CHEUNG, C.M.; AWAN, M.A.; SANDRAMOULI, S.: "Prevalence and clinical findings of tamsulosinassociated intraoperative floppy-iris syndrome". J. Cataract. Refract. Surg., 32: 1336, 2006.        [ Links ]

4. PRINGLE, E.; PACKARD, R.: "Antipsychotic agent as an etiologic agent of IFIS". J. Cataract. Refract. Surg., 31: 2240, 2005.        [ Links ]

5.BLOUIN, M.C.; BLOUIN, J.; PERREAULT, S. y cols.: "Intraoperative floppy-iris syndrome associated with alpha1-adrenoreceptors: Comparison of tamsulosin and alfuzosin". J. Cataract. Refract. Surg., 33: 1227, 2007.        [ Links ]

*6. SHUGAR, J.K.: "Use of epinephrine for IFIS prophylaxis". J. Cataract. Refract. Surg., 32: 1074, 2006.        [ Links ]

7. WILSON, M.E. Jr.; TRIVEDI, R.H.; MISTR, S.: "Pediatric intraoperative floppy-iris syndrome". J. Cataract. Refract. Surg., 33: 1325, 2007.        [ Links ]

*8. BENDEL, R.E.; PHILLIPS, M.B.: "Preoperative use of atropine to prevent intraoperative floppy-iris syndrome in patients taking tamsulosin". J. Cataract. Refract. Surg., 32: 1603, 2006.        [ Links ]