A prospective study has found that modifications to one's cat­a­ract surgery technique can result in out­comes for patients on alpha-1 blockers like Flomax (tamsulosin) that are at least as good as those en­joyed by patients not on such agents. The trick, however, is to make sure the patient tells the surgeon of his alpha-blocker history preop so the appropriate technique modifications can be made.

In the study, surgeons at 10 centers performed cataract surgery on 160 cataract patients who were taking Flomax. To compensate for the ef­fects of the drug on the iris dilator muscle, the surgeons were allowed to use modified techniques as they saw fit. The following three techniques emerged from the study as being the most helpful.

"From a pharmacologic viewpoint, we know that one of our problems intraoperatively is progressive miosis, that is, the pupil sphincter muscle is unopposed because the dilator is weakened," explains Los Angeles surgeon Samuel Masket, who took part in the study. "And the traditional di­lating agents are not strong enough to totally weaken the constrictor muscle of the pupil. Atropine is the most ef­fective agent we have, but it has to be started several days in advance of surgery. The problem is, if we don't know prior to surgery that the patient has taken an alpha blocker, we can't start atropine before surgery." The appropriate regimen is atropine t.i.d. for two days before surgery. Dr. Masket notes, how­ever, that following this regimen increases the risk for urinary retention if the patient stops taking Flomax, so patients should be en­couraged to keep taking their alpha blocker.

In addition, the surgeons found that stimulating the weakened dilator muscle with concentrated mydriatics during the surgery itself was beneficial. Joel Shugar, MD, in Jupiter, Fla., advocates using epinephrine injected beneath the iris.

"From my viewpoint, using atropine prior to surgery and intraocular epinephrine at the time of surgery has enabled 19 out of 20 cases to be performed as routine sur­geries," says Dr. Masket. "The one outlier was a patient whose pupil was so small prior to surgery that he required one of the other strategies, such as iris hooks."

In addition to the pharmacologic strategy, the study also found mechanical aids, such as iris hooks or pupil dilating rings, to be effective. The third aid that proved helpful in the study was the use of a viscoelastic agent to expand the pupil and keep it away from the incision. Dr. Masket says either Healon 5 (AMO) or DisCoVisc (Alcon) works particularly well for this.

"These concepts are complementary rather than competitive," says Dr. Masket. "So, we can initiate a pharmacologic approach. If that isn't adequate, we can then consider the second approach, which would be either mechanical devices to expand the pupil or heavy visco agents and reduced fluidics. Each one just builds on the one before it depending on how much help we need intraoperatively."

To realize the benefits during surgery, however, surgeons say the doctor's knowledge about alpha-1 blocker use is critical.

"Patients who haven't taken Flo­max as long as five years before the surgery and who are no longer taking it can suffer floppy iris syndrome," said the study organizer David Chang, MD, in a conference call on both the study and dealing with the effects of alpha-1 blockers.

Lawrence Ross, MD, president of the American Urological As­so­ciation, also participated in the telephone discussion. He noted that physicians should be aware that it's not necessarily just the male patients who can be on alpha blockers. "Alpha blockers are also given for other urinary tract symptoms," he said. "So some women may be on these drugs too. There­fore, it's im­portant to recognize the class of drugs when taking a history of a patient, and not just looking for prostate patients who take it." Other alpha-1 blockers to watch for include terazosin (Hytrin), doxazosin (Cardura) and alfuzosin (Ur­oxatral).

The full results of the study will be presented at November's meet­ing of the American Academy of Oph­thalmology.


Allergan Offers Funding Opportunity for Fellows
Allergan has announced the formation of the Allergan Horizon Grant Program, which Allergan will fund with $1 million over two years. The program will provide awards to academic medical institutions to support fellows seeking to develop careers in academic medicine and fund fellowship programs that conduct clinical research in the diagnosis or pharmacological treatment of glaucoma, corneal and retinal diseases.

"Recognizing increased competition for funding in ophthalmology, Allergan developed the Horizon Grant Program to support research conducted as part of fellowship programs to advance the practice of ophthalmology and the prevention and treatment of eye disease," said Steven James, MD, vice president of medical affairs. "This program underscores Allergan's long-term commitment to the ophthalmology community and to the support of research to advance our understanding of ocular disease and improve patient care."

Grant applications should be submitted by the department chair, division chief or fellowship director of the academic institution and must be received by Allergan Medical Affairs, 2525 Dupont Drive, Irvine, CA 92612, no later than Sept. 30, 2006. Allergan plans to review grant applications with the assistance of an academic advisory board, and will retain sole discretion in determining grant recipients. The Allergan Horizon Grant Program recipients will be announced at November's annual meeting of the American Academy of Ophthalmology in Las Vegas. For more information and applications for the program, visit allerganhorizongrants.com.


FDA Clearance for MEL 80 Excimer Laser System

The Food and Drug Ad­mi­ni­stra­tion last month cleared Carl Zeiss Meditec's MEL 80 excimer laser system for refractive surgery in the United States. The company has more than 750 excimer systems already delivered to customers internationally.

Results from clinical studies found that 93 percent of patients were corrected at three months to 20/20 or better visual acuity, and 41 percent were corrected to 20/12.5 or better at six months. Results also showed that 85 percent of patients achieved within 0.5 D of the in­tended correction at three months postoperative follow up. The MEL 80 laser uses a small spot size and Gaussian beam profile. The ablation process is also very fast, so there is less dehydration of the eye. The thermally optimized distribution of the laser firing pattern also protects the stroma, despite the system's high ablation speed, the company says. Since the patient only needs to concentrate on the fixation light for a few seconds, patient stress is reduced.

"The MEL 80 has su­perior characteristics that make it extremely advanced," said Mark Packer, MD, clinical associate professor at Oregon Health and Science Uni­ver­sity, Port­land, Ore., and a principal investigator of the clinical trial. "Be­cause of its speed, the amount of time the cornea is exposed is re­duced and the over­all treatment procedure is significantly shortened. Additionally, the laser is able to preserve the natural curvature of the cornea ultimately improving the quality of vision." Pre­parations for commercial launch of the MEL 80 in the United States are now being finalized.

"We believe that the excellent results from the FDA clinical studies will further im­prove the reputation of the MEL 80 as one of the leading refractive laser systems," said Jim Taylor, president and CEO of Carl Zeiss Meditec. "In addition to the advanced excimer laser platform offered by our MEL 80, we have also pursued the development of an advanced femtosecond laser system for flap creation. The ongoing clinical testing of these femtosecond technologies has been both more rapid and more promising than we had anticipated, and a 510k has recently been filed. As a result, our intent is to bring a truly unique and comprehensive offering to our customers."


Intestinal Surgery Tied to Late Vision Decrease

A study at Baylor College of Me­di­cine's Cullen Eye In­stitute suggests that vitamin A deficiency should be suspected in patients with unexplained decreased vision and a history of intestinal surgery, regardless of the timing of the surgical procedure. Three patients in the retrospective review developed decreased vision from vitamin A deficiency more than 18 years after their intestinal surgery, ac­cord­ing to the study in the British Journal of Ophthalmology.

Vitamin A deficiency, often presenting with nyctalopia, has been described in a number of patients with malabsorption as a result of intestinal bypass surgery and, more recently, bariatric surgery. In these reports vitamin A deficiency developed within several years of gastric or intestinal surgery.

BJO 2006;90:955-956 

SEE/ACES Teams with Review
The Society for Excellence in Eyecare and the Am­erican College of Eye Surgeons have entered into a contractual relationship with Jobson Medical In­for­mation's Review of Ophthalmology Group to manage the annual SEE/ACES Island Meeting. "This agreement with the Review will allow us to grow the meeting by providing meeting planning expertise, greater marketing and press coverage of our meeting to the general ophthalmology population. We have grown this meeting using our limited re­sources and the time has come to move to the next level to stay ahead of the growth curve of this meeting," said Maurice John, MD, SEE president.

The board is committed to maintaining the unique­ness of the Island meeting, which is to provide access to speakers, vendors and peers who attend the meeting. "The Review is a respected, wide­ly distributed, and well-read journal. We be­lieve their resources will allow us to provide greater coverage of our meeting and allow us to attract even more attendees and speakers," said Jack Kearney, MD, program chair.

The SEE Island/Quality Surgery XXI Seminar will be held Feb. 16 to 20, 2007 at the Atlantis Resort in Paradise Island, Bahamas. The meeting will once again offer an administrative track. Practice administrators and other key staff members are welcome to take part in tailored programs. For more infor­ma­tion and registration, visit aces-abes.org or excellenteyesurgery.com.

The Atlantis Resort in Paradise Island, Bahamas.