Patients taking systemic alfuzosin for benign prostatic hyperplasia (BPH) were less likely to experience moderate or severe intraoperative floppy iris syndrome (IFIS) during cataract surgery than patients taking tamsulosin (Flomax, Astellas Pharma), according to a head-to-head comparison published online December 5 in Ophthalmology.
Because the BPH drugs are both linked to permanent changes in the iris and associated with increased risk for IFIS, the authors say patients with symptomatic BPH and cataracts may want to try alfuzosin first.
David F. Chang, MD, clinical professor, University of California, San Francisco; immediate past president of the American Society of Cataract and Refractive Surgery; and immediate past chair of the American Academy of Ophthalmology Cataract Preferred Practice Pattern Committee, and colleagues compared the incidence and severity of IFIS during routine cataract surgeries in 226 eyes: 70 in patients receiving systemic tamsulosin, 43 in patients receiving systemic alfuzosin, and 113 in patients with no history of systemic alpha1-antagonists. The surgeries were performed in France, where alfuzosin use is far more common.
Each phacoemulsification and intraocular lens implantation procedure was recorded on video and reviewed remotely by 2 investigators. The reviewers were not told what medication the patients were taking. They diagnosed IFIS and graded its severity as absent, mild, moderate, or severe. Mild cases showed billowing only, moderate cases showed billowing and either iris prolapse or 2 mm or more of pupil constriction, and severe cases included billowing accompanied by iris prolapse and 2 mm or more of pupil constriction. Use of intracameral phenylephrine or epinephrine was not permitted during the procedures. In a substudy, investigators looked at the effect of eliminating the use of intracameral epinephrine in the irrigation bottle.
IFIS occurred in 34.3% (24/70) of the tamsulosin group, 16.3% (7/43) of the alfuzosin group, and 4.4% (5/113) of the control group. Neither posterior capsular rupture nor significant surgical complications occurred in the case or control groups.
The findings indicate that severe IFIS was statistically more likely with tamsulosin than alfuzosin (P = .036). Together with the control group, the substudy showed that moderate to severe IFIS can occur even in low-risk eyes, with no history of alpha blocker, in the absence of epinephrine use for irrigation.
"Benign prostatic hyperplasia and cataracts are 2 of the most common conditions that normally occur with aging in men. So as the population ages, the prospect of IFIS will only increase," Dr. Chang told Medscape Medical News. Dr. Chang and coauthor John R. Campbell, MD, who is in private practice in Marin, California, were the first to report the symptoms, and name the syndrome, in 2005. "From the outset, we were impressed that [IFIS] seemed more often associated with tamsulosin than with nonselective alpha blockers, such as terazosin or doxazosin."
Tamsulosin, alfuzosin, terazosin, and doxazosin are all alpha1-adrenergic antagonists, but tamsulosin is the only one that is selective for the alpha-1A receptor subtype that predominates in the prostate and iris smooth muscle. Tamsulosin and alfuzosin are clinically uroselective, with less incidence of postural hypotension.
"Our study showed that tamsulosin was more likely to cause severe IFIS," Dr. Chang told Medscape Medical News. "Therefore, a patient needing to start a uroselective alpha-1 antagonist might want to try alfuzosin first if they had any sign of a cataract."
Dr. Chang said urologists and others who treat BPH were reluctant to let go of an effective drug that eliminated the postural hypotension. "There was some resistance. And there was not enough strong evidence, meaning prospective, masked clinical trials, to conclude that 1 alpha blocker was worse than another."
This trial provides that evidence, Dr. Chang said.
"This article was excellent," Ike K. Ahmed, MD, FRCSC, assistant professor and division head, University of Toronto Division of Ophthalmology, Ontario, Canada, told Medscape Medical News. Dr. Ahmed, who also is the research director of the University of Toronto Kensington Eye Institute, was not involved in the current study. "Tamsulosin is a very common drug, and its complication rate is higher from a surgical perspective. From an eye perspective, alfuzosin appears to be a less problematic drug," he said.
Although surgeons can minimize complications resulting from tamsulosin if they know a patient has taken the drug, "if we find a drug that works just as well as tamsulosin for BPH, then that will make a difference," Dr. Ahmed added.
Rosa M. Brega-Mele, MD, FRCSC, professor of ophthalmology, University of Toronto; director of cataract surgery at the Kensington Eye Institute; and chair of the American Society of Cataract and Refractive Surgery Cataract Clinical Committee, noted that even with alfuzosin's lower risk profile for IFIS, surgeons still need to exercise caution. "We need to be aware that there is still a risk of the iris responding to the nonselective alpha1 antagonist," she told Medscape Medical News.
"On the other side of the coin, the urologist and family doctors, if the efficiency of either drug is pretty good for the treatment of BPH, then alfuzosin might be the better choice," she said. Dr. Brega-Mele was not involved with the current study.
Dr. Chang said men who are about to be treated for BPH should, when possible, have necessary cataract surgery first. In general, he said, primary care physicians are not aware of the cataract surgery complications associated with tamsulosin. "We polled primary care physicians in the [University of California, San Francisco,] network in an online poll asking about their familiarity with IFIS and their prescribing patterns. It became very clear from the poll that the majority of primary care doctors do not know about IFIS, and about the link of alpha-blockers with IFIS, and the fact that certain alpha-blockers are more likely to cause IFIS than others. With that in mind, we're in the process of approaching other [clinician] organizations about circulating this information to their members."
The authors and commentators have disclosed no relevant financial relationships.
Ophthalmology. Published online December 5, 2013. Abstract
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Cite this: Alfuzosin for BPH Linked to Fewer Snags in Cataract Surgery - Medscape - Feb 13, 2014.