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News in Review
A Look at Today’s Ideas and Trends
Of the 16 million Americans aged 60 and older who have cataracts each year, a good many of them also have another common condition of aging: benign prostatic hypertrophy. More than 4 million times a year, elderly American men ask a doctor for help with BPH.
Recently two California ophthalmologists discovered that the BPH drug Floma (tamsulosin) causes iris complications during phacoemulsification. (Interestingly, Flomax is prescribed for some women with urinary retention.)
The pair’s peer-reviewed paper on what they call intraoperative floppy iris syndrome (IFIS) is being rushed into print this spring.1 And a January summary of their findings in a trade magazine sent cataract surgeons to online chat groups for advice on how to identify and deal with the condition.
Fortunately, authors David F. Chang, MD, of Los Altos, and John R. Campbell, MD, of San Rafael, had answers:
Drs. Chang and Campbell cautioned that iris prolapse by itself isn’t enough to denote IFIS. The syndrome is defined by a combination of three consistent characteristics: a floppy iris that billows in response to normal intraocular fluid currents, a strong propensity to iris prolapse and progressive miosis intraoperatively. “There are other causes of iris prolapse or of intraoperative miosis,” said Dr. Chang. “However, it is this triad of features that indicates that you are dealing with IFIS due to Flomax.”
Dr. Chang said he sees no need for urologists to stop prescribing Flomax for their patients with BPH at this time. “Iris retractors or other pupil expansion devices will assure a large pupil size throughout surgery in IFIS eyes,” he said. “Surgeons typically don’t use these devices for most small pupil cases because they are more expensive, time-consuming and harder to insert after the capsulorhexis has been created.” Other ophthalmologists have suggested using Healon 5 with low aspiration parameters.
“By knowing in advance when IFIS will occur, surgeons will be able to alter their usual method of small pupil management,” he said. “As long as ophthalmologists know how to anticipate and manage IFIS, there is no reason why Flomax patients shouldn’t have excellent results from cataract surgery.”
Dr. Chang is planning a multisurgeon prospective follow-up study to assess this prediction.
1 Chang, D. and J. Campbell. J Catact Refract Surg 2005; issue undetermined at EyeNet’s press time.
2 J Cataract Refract Surg 2002;28(4):596–598.
The menstrual cycle appears to correlate with measurable changes in the optic nerve head and poorer performance on the most sensitive type of visual field test, suggesting a need for clinicians to consider this in interpreting such changes in their younger patients, according to a pair of studies by Turkish researchers.
The group, from the department of obstetrics and gynecology at Akdeniz University in Antalya, Turkey, detailed the changes they measured as estrogen declines and progesterone rises in the menstrual cycle’s luteal phase.1, 2
In the first study, they used a scanning laser ophthalmoscope to examine the optic nerves of 38 healthy young women in the follicular, ovulatory and luteal phases of their menstrual cycles.
They found the disc area did not change during the cycle, but the neuroretinal rim area decreased significantly in the luteal phase. In the same phase, the linear cup-to-disc ratio, cup-to-disc area ratio and cup area all increased significantly.
The second study used standard achromatic perimetry (SAP) and short-wavelength automated perimetry (SWAP) to test 59 young women during the follicular and luteal phases of their menstrual cycles.
SWAP revealed a significantly decreased mean sensitivity value in the women during the luteal phase (P < 0.05), but no statistically significant change with SAP.
Brian A. Francis, MD, assistant professor of ophthalmology at the University of Southern California, concluded, “Clinicians should be aware of a patient’s hormonal status (both endogenous and exogenous) when evaluating them for glaucoma diagnosis and progression.”
1 Akar, M. E. et al. Acta Ophthalmol Scand 2004;82(6):741–745.
2 Akar, Y. et al. Ophthalmologica 2005;219(1):30–35.
Eye and Body
Retinopathy in a patient might signify systemic microcirculatory problems that could lead to congestive heart failure (CHF), especially if the patient doesn’t have diabetes or hypertension, the Atherosclerosis Risk in Communities (ARIC) study has concluded.1
Over seven years, CHF was three times as likely to occur in these healthy-seeming patients than in their peers without retinopathy lesions.
Even in patients who did have cardiovascular risk factors such as diabetes, hypertension and smoking, the presence of retinal lesions doubled their adjusted relative risk for CHF, the ARIC study found. The impact was especially important in diabetics.
ARIC is a population-based, prospective cohort study that followed patients for seven years during the 1990s. Retinal photographs of 11,617 subjects were graded and correlated with medical and death records.
The results add congestive heart failure to the list of larger cardiovascular system problems at which a retinal examination can hint. The list includes: coronary heart disease and the inflammation and endothelial dysfunction that lead to plaque formation in blood vessels.
The authors re-emphasize referring patients for cardiovascular follow-up. Retinal exams might be able to improve risk prediction for CHF, they write. “In particular, patients with diabetes and signs of retinopathy may benefit from further assessment of CHF risk, such as echocardiography to detect asymptomatic left ventricular dysfunction, if clinically indicated.”
1 Wong, T. Y. et al. JAMA 2005;293:63–69.