Mark H. Blecher
• 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
Occurs in males > females
In the US, occurs in ∼2–3% of cataract surgeries
• Most frequent and severe in patients exposed to selective 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
– Dutasteride (Avodart)
– Saw palmetto
– Antipsychotic drugs
Avoidance of associated medications
• 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.
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)
• Hair loss
• Psychiatric disturbances
The incidence of benign prostatic hyperplasia (BPH) is ∼50% in men >50 years and 90% in men >85 years of age.
Important to screen all patients for current or past use of all associated agents
Poor or slow dilation preoperatively may suggest IFIS
• Poor preoperative dilation
– Prior injury, inflammation, infection, or topical miotic use
• Iris prolapse
– Short or inadequately constructed wounds
– High intracameral pressure
• 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)
• 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
• 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)
• 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.
• 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.
• 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.
364.81 Floppy iris syndrome
• 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.