I regret to inform that I had another complication with another FLOMAX case yesterday. While I used intracameral epi, iris hooks, and had great visualization, I still managed to break capsule leave cortex, drop some nucleus.
Then, shaken by the first case, I dropped a nucleus in my 2nd case of six yesterday.
My confidence is at an ebb.
I'm thinking of punting complicated cases for awhile, until i feel more confident.
Incidence one prospective study of 1298 cases showed tamsulosin accounted for only 26% of alpha 1 antagonists but for 71% all iris prolapse
The Effect of the α 1 -Adrenergic Receptor Antagonist Tamsulosin (Flomax) on Iris Dilator Muscle Anatomy Ricardo Santaella, MD, John Destafeno, MD, Sara Miller, PhD, Sandra Stinnett, DrPH, Alan Proia, MD, Terry Kim, MD Albert Eye Research Institute Duke University Medical Center Durham, North Carolina
Control Subject Tamsulosin Subject Light Microscopy Morphometric Results Representative sample photomicrographs * Indicates iris dilator smooth muscle. (H&E) Mean (micrometers) Tamsulosin group n=26 Control Group n=26 P-Value* Iris Dilator Muscle Thickness 6.62 (SD=2.22) 8.20 (SD=1.77) 0.004 Iris Stromal Thickness 275.98 (SD=68.17) 274.65 (SD=57.96) 0.925
Stopping Flomax – benefit unproven - the effect can last years
Intercameral injection of alpha 1 agonists – ie phenylephrine –can help with dilation and increase iris rigidity by increasing smooth muscle tone- Joel Shugar’s epi-Shugarcaine mixture (has greater effect if neo is not used preop
Topical atropine 1% tid for 1-3 days preop:good preop dilation but not as good controlling size intraop – could cause urinary retention – do not stop flomax if using atropine