Recommendations

The Royal Australian and New Zealand College of Ophthalmologists

3.
Don't prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.

Alpha-1 adrenergic blockers such as tamsulosin nearly always affect the structural integrity of the iris and this can be permanent after only a few doses of the drug. As a result, “intraoperative floppy-iris syndrome” often results when intraocular surgery, especially cataract surgery, is performed. This can lead to iris damage and post-operative glare problems but also increase the risk of more serious complications such as posterior capsule rupture, vitreous loss, macular oedema and retinal detachment. This risk is up to ten times greater in some series.

Surgeons can minimise the risk if they know a patient has taken the drug. Patients on long waiting lists can sometimes forget to tell the ophthalmologist they have been prescribed it whilst waiting for surgery. Better still, if the need for taking tamsulosin is not absolute and immediate, delaying its prescription until after any impending cataract surgery is performed would be in the patient’s best interest.

Supporting evidence
  • Doss EL, Potter MB, Chang DF. Awareness of intraoperative floppy-iris syndrome among primary care physicians. Journal of Cataract & Refractive Surgery 2014;40(4):679-80.
  • Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract & Refractive Surgery 2005;31(4):664-73.
  • Ng DT, Rowe NA, Francis IC, Kappagoda MB, Haylen MJ, Schumacher RS, et al. Intraoperative complications of 1000 phacoemulsification procedures: a prospective study. Journal of Cataract & Refractive Surgery 1998;24(10):1390-5.
  • Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. Journal of Cataract & Refractive Surgery 2010;36(6):898-905.
  • Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114(5):957-64.
  • Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin staged approach. Journal of Cataract & Refractive Surgery 2006;32(10):1611-4.
  • Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: results in 30 consecutive cases. Journal of Cataract & Refractive Surgery 2008;34(5):835-41.
How this list was made How this list was made

RANZCO has undertaken a multi-stage consultation process to ensure that the entire spectrum of medical eye specialists in Australia and New Zealand can contribute to the process of identifying and refining the top five recommendations. The first stage included a survey of fellows to identify possible recommendations, which were then narrowed down and by a dedicated “Choosing Wisely” committee of RANZCO members. A second survey was then sent to all members to provide feedback on the list of five and received a high response rate. Based on the extensive feedback received via the survey, RANZCO’s “Choosing Wisely” committee crafted the final wording of the top five recommendations. Finally, the RANZCO board discussed and approved the recommendations.