Though Ipecac and Mr. Mega would be a powerful build in a normal run, My Reflection causes tears to loop back around towards Lazarus, forcing him to have to avoid not only enemy tears but his own as well. This also makes aiming tears significantly harder.
The 1 pip and 6 pip dice rooms will not reroll the starting items for this challenge but will reroll any others.
Lazarus has one extra life by default, granting him some survivability.
Because of My Reflection, the range is diminished. With a little practice, however, it can be easy to tell how far away the shot will travel. Lining up enemies with that distance will make it easier to score direct hits that won't come back. One way to track this is by the shadow of the Ipecac tear.
Ipecac's explosive tears can be used to break rocks, mushrooms, and skulls, and open secret rooms.
Crawl Spaces are very valuable because of the lack of Treasure Rooms, making the destruction of all encountered rocks a viable strategy. Most items that can be acquired this way are useful, but Pyromaniac and Host Hat are especially noteworthy for their ability to prevent all self-damage inflicted on Lazarus.
While Dr. Fetus will not prevent any damage inflicted by bombs, it will massively increase Lazarus's damage.
It is possible to hit enemies without having to worry about My Reflection by moving in tandem with the Ipecac tear, making the shot faster. This method only works with a higher Speed stat.
A higher Shot Speed stat allows the tears to fly further away from Lazarus before returning, allowing enemies to be shot from further away while reducing the risk of being caught in the blast radius.
A lower Range stat is advantageous. It shortens the way back to Lazarus whereas a high Range stat seems to home him.
The Magic Fingers item is a common shop item that is affected by Ipecac's damage increase. This makes it extremely viable as an alternative damage source to Ipecac tears, especially in runs with a large coin count.
If Envy is encountered, and it drops Shoop Da Whoop!, it is highly advised to pick it up. Due to the item's relatively quick recharge time, and the fact that its damage is greatly increased by Ipecac, it can be used as an ace in the hole to clear challenging rooms and easily defeat bosses.
Death's Touch allows the tears to do damage in-flight, making it significantly easier to hit enemies.
Technology is an immensely useful item that can be acquired from the Boss Rush, as it overrides Ipecac, granting infinite range and no explosive damage.
Gnawed Leaf is another useful item from crawl spaces causing Lazarus to turn into a statue just before the Ipecac tears hit him. This is only really useful for destroying objects.
Succubus is an incredibly useful familiar, as its damage scales with Lazarus's. Succubus allows the challenge to be cleared without using tears as it only takes a few seconds for it to clear out a regular-sized room autonomously.
Familiars that mimic Lazarus's tears, such as Fate's Reward, are not recommended for this challenge. While they do increase Lazarus's overall damage output, they are very difficult to avoid, as they are usually fired directly towards Lazarus.
Spirit Sword overrides the explosive projectiles from Ipecac if Lazarus is not at full health, making self-damage far less likely at the cost of making Lazarus into a close-range fighter.
Brimstone and Sulfur are extremely useful for cleaning rooms and has an absurd synergy with worm trinkets.
The Devil Room at the end of the It Lives boss fight will contain regular Deals with the Devil instead of a trap door, as the challenge requires Lazarus to go to the Cathedral.
If the player somehow manages to end up going to Sheol instead of The Cathedral (i.e. through a trapdoor in The Womb II), defeating Satan will successfully finish the challenge and erroneously unlock the achievement.
XboxOne If the game crashes during the challenge and is reloaded, Lazarus will lose Ipecac and have his normal tears.