Mark H. Blecher

BASICS

DESCRIPTION

• An iris abnormality that may manifest preoperatively with poor pupil dilation and may manifest intraoperatively with some or all of the following findings:

– Billowing of the iris stroma during normal irrigation

– Iris prolapse to corneal incisions

– Poor maintenance of dilation with progressive miosis (pupil constriction)

– Ineffectiveness of pupillary stretching to maintain pupil expansion

EPIDEMIOLOGY

Occurs in males > females

Prevalence

In the US, occurs in ∼2–3% of cataract surgeries

RISK FACTORS

• Most frequent and severe in patients exposed to selective α₁-antagonists

Associated α₁-antagonists:

– 1A selective

– Tamsulosin (Flomax): up to 90% of patients taking this drug may have IFIS

– Alfuzosin (Uroxatral): up to 15% of patients taking this drug have IFIS

– Silodosin (Rapaflo): unknown%

– Nonselective: lower risk

– Terazosin (Hytrin)

– Doxazosin (Cardura)

– Naftopidil (Flivas)

Use of other medicines/supplements: lowest risk

– 5-alpha reductase inhibitors

– Finasteride

– Dutasteride (Avodart)

– Saw palmetto

– Antipsychotic drugs

GENERAL PREVENTION

Avoidance of associated medications

PATHOPHYSIOLOGY

• Alpha 1A iris smooth muscle adrenoreceptor may be blocked by associated antagonists.

• Blockage may lead to loss of dilator muscle tone.

• Decreased dilator tone may lead to poor dilation and intraoperative floppiness.

ETIOLOGY

IFIS may occur even with short-term exposure to associated medications (≥2 days reported) or use in the distant past

COMMONLY ASSOCIATED CONDITIONS

Any condition treated with associated medications

• Benign prostatic hypertrophy

• Prostate cancer

• Urinary retention (men/women)

• Hypertension

• Hair loss

• Psychiatric disturbances

Geriatric Considerations

The incidence of benign prostatic hyperplasia (BPH) is ∼50% in men >50 years and 90% in men >85 years of age.

DIAGNOSIS

HISTORY

Important to screen all patients for current or past use of all associated agents

PHYSICAL EXAM

Poor or slow dilation preoperatively may suggest IFIS

DIFFERENTIAL DIAGNOSIS

• Poor preoperative dilation

– Prior injury, inflammation, infection, or topical miotic use

• Iris prolapse

– Short or inadequately constructed wounds

– High intracameral pressure

TREATMENT

MEDICATION

• Stopping associated agent preoperatively

– May improve dilation but will not typically decrease IFIS severity

– Most surgeons do not stop these agents

• Preoperative atropine

– Improves dilation but does not reliably decrease IFIS severity

• Intracameral α₁-agonist injections (preservative-free only)

– Epinephrine 1:1000 mixed 1:3 or 1:4 with balanced salt solution to buffer

– Phenylephrine (not available in the US)

ADDITIONAL TREATMENT

General Measures

• Highly cohesive ophthalmic viscoelastic devices (OVD)

– Sodium hyaluronate 2.3% (Healon5) may facilitate pupil expansion and prevent iris movement

• Other specialized viscoelastics

– Hyaluronic acid 1.6% and chondroitin sulfate 4.0% (DisCoVisc) may remain in the eye longer with higher flow rates

SURGERY/OTHER PROCEDURES

• Longer, more stable, wound tunnels may decrease iris prolapse

• Pupil expansion

– Pupillary rings: Malyugin (Microsurgical technology), Graether silicone ring (Eagle Vision), 5S Pupil Ring (Morcher GmbH), Perfect Pupil (Milvella Ltd.)

– Iris retractors/hooks: Disposable 6–0 nylon (Alcon) or reusable 4–0 polypropylene (Katena Products, FCI, Oasis Medical)

ONGOING CARE

PATIENT EDUCATION

• Patients should be informed of risks of associated medicines.

• Prescribing physicians should consider referring patients to an ophthalmologist for consultation before starting these medicines.

• Patients must inform their ophthalmologists if they are currently or have ever taken these medicines.

COMPLICATIONS

• IFIS is associated with a higher rate of posterior capsule rupture, vitreous loss, and iris damage.

• The rate of complication is highest when the ophthalmologist is unaware of patient use of associated medicines.

ADDITIONAL READING

• Chang DF, Braga-Mele R, Mamalis N, et al. ASCRS white paper: Clinical review of floppy-iris syndrome. J Cataract Refract Surg 2008;34:2153–2161.

• Chang DF, Campbell JR. Intraoperative floppy-iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005;31:664–673.

• Chang DF, Osher RH, Wang L, et al. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114:957–964.

CODES

ICD9

364.81 Floppy iris syndrome

CLINICAL PEARLS

• IFIS is associated with α₁-antagonist use.

• Outcomes are best if IFIS risk is identified preoperatively.

• Several strategies can be used to successfully manage IFIS intraoperatively.

• Patients and physicians should be educated about IFIS risks.

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