Floppy Iris Syndrome (IFIS)

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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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Floppy Iris Syndrome (IFIS)

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