1. Mitchell A Jackson MD Lake Villa IL USA mjlaserdoc@msn.com Relevant financial disclosure: Member Bausch + Lomb speaker’s bureau

2.  First described by Chang and Campbell in 2005 1  Excessive billowing/floppiness of mid-peripheral iris may lead to: Iris prolapse at main and/or side incisions Progressive miosis Poor preoperative pupil dilation  Complication rate overall is 77% 2 Posterior capsule rupture/vitreous loss (23%) Iris trauma (52%)  49% of ophthalmologists would have their own cataract removed first-even at early stage-prior to starting tamulosin (1) Chang D, Campbell J. JCRS 2005;31:664-67. (2) Chang D et al. J Cataract Refract Surg 2008;34:1201-1209.

3.  Well established with systemic use of alpha-1 adrenergic antagonists Tamsulosin (Flomax), Silodosin (Rapaflo) – BPH tx  Can even occur with nonspecific alpha-1 antagonists Terazosin (Hytrin), Doxazosin (Cardura), Alfuzosin (Uroxatral)  Alpha-1a receptor subtype predominates in prostate and iris dilator muscle  Stopping treatment preop is unpredictable and IFIS has been reported for up to several years after stopping tamulosin

4.  Masket 1 Preoperative atropine 1% drops tid for 1-2 days Intraoperative 1:2500 epinephrine hydrochloride Potential acute urinary retention so don’t stop tamulosin  Packard 2 and Shugar 3 Intracameral phenylephrine/epinephrine preservative-free solutions in appropriate diluted mixture  Bimanual microincisional cataract surgery with its smaller, tighter incisions plus keeping irrigation inflow anterior to the iris may also lessen IFIS 4 (1) Masket S, Belani S. JCRS 2007;33:580-582.(2) Gurbaxani A, Packard R. Eye 2007;21:331-332. (3) Shugar J. JCRS 2006;32:1074-1075.(4) Chang D, Campbell J. JCRS 2005;31:664-67.

5.  OVD “donut” in anterior chamber1 Cohesive OVD (Healon 5) peripherally and dispersive OVD (Viscoat) centrally Dispersive OVD resists aspiration, delaying evacuation of cohesive OVD over the iris  Mechanical expansion devices Most are bulky and difficult to position in small pupils (<4 mm) or shallow anterior chambers Newer Malyugin rings limited to 2.2 mm incision size  Iris Retractors/Hooks Subincisional (main and side) hooks (4) retract iris downward and out of path of phaco tip and 2nd instrument (Diamond configuration)2 Subincisional hook (1) at main incision with adequately dilated pupil3 (1) Chang D et al. Ophthalmology. 2007;114:957-64.(2) Oetting T, Omphrov L. JCRS 2002;28:596-598. (3) Tint et al JCRS 2009;35:1849-1852.

6.  Simple and efficient  Combine microincision cataract surgery (MICS) through 1.8 mm incision with: Single iris hook if pupil dilation is good Diamond 4-hook technique if pupil dilation is poor  Stellaris fluidics provides high level of chamber stability  Tight seal of MICS seems to minimize iris prolapse toward phaco incision

7.  Retrospective review of 20 eyes of patients who were prescribed tamulosin  Good pupil dilation  Planned uncomplicated 1.8 mm coaxial MICS with Stellaris system  Topical and intracameral anesthesia only

9.  No complications No posterior capsular/zonular compromise or vitreous loss No iris trauma or pigmentation changes  Phaco times approached those of non- tamulosin cases reported in Stellaris system evaluation

10. Mean Effective Phaco Time (EPT) Power 1.8mm Coaxial-MICS 4.6 sec12.5% 1.8mm Biaxial-MICS 2.8 sec10.8% 2.8mm Standard Cataract Surgery 5.1 sec13.0% Data from Bausch + Lomb

11.  Stellaris 1.8 mm coaxial MICS and single subincisional iris retractor maintains stable anterior chamber with minimal to no iris prolapse  With poorly dilated pupil, use 4 hooks in diamond configuration  Phaco efficiency and times essentially unchanged with tamulosin cases acting like and approaching safety rates of non-tamulosin cases