23 Intraoperative Floppy Iris Syndrome Board certification may be a nuisance, but some of the board questions surprisingly pop up in your everyday practice. Take this question, which “walked into my office” in the form of a patient with a damaged iris sphincter and another patient with a broken posterior capsule—issues that could not be resolved after problems were encountered during the patients’ cataract surgery. Here is the question: As with any multiple choice question, I make certain I know what is being asked. It seems like a fairly subjective question, and I believe it is referring to intraoperative floppy iris syndrome (IFIS). Funny, I’d never seen it presented quite this way. How to answer this one? I’ll take it step by step. What do we know about treating IFIS? Since the description of IFIS by David Chang and John Campbell in 2005, IFIS has undoubtedly become the most frequently encountered condition to potentially complicate an otherwise routine cataract surgery. In its mild form, the iris simply billows. Moderate cases have the pupil shrinking. In severe cases, iris prolapse occurs. Potential problems range from iatrogenic capsule rupture to dropped nuclei to retained fragments with the risk of prolonged inflammation and corneal endothelial damage. Any number of techniques have been described to decrease the complications associated with IFIS. Many of these steps have to be taken in anticipation of IFIS. To do this, we have to identify the patients at risk. But that’s the catch—it is called intraoperative floppy iris syndrome because it is not easy to spot in the office. We can spot pseudoexfoliation or Fuchs’s syndrome at the slit lamp, but not IFIS. To go back to the question, I’ll just answer with option 1, and be justifiably content. There is absolutely no reason in my practice that I would ever consciously restrict the application of my best skills for any patient requesting my services. That little nagging voice bugs me as I try to move on. It reminds me that if I’m doing anything to separate out the IFIS patients, the correct answer might not be what I think it is. How are we trying to identify patients at risk for IFIS? I’ll start with men currently on Flomax. But the drug’s effects may persist years after its discontinuation. So, then, we need to identify men who have ever taken Flomax. Generics being prevalent, we ask specifically about tamsulosin as well. Did we get them all? No, we didn’t get them all. Wives will point out their husband’s fallibility when it comes to remembering his own medical history. Besides, doesn’t having prostate surgery mean you don’t have the problem any more? I’ll change the approach and ask men about trouble urinating due to prostate problems at any time at all in the past, and assume they’ve taken the drug at one point or another if they agree. Better results, but we’re still going to miss the women with a history of off-label use of tamsulosin. And, of course, the various patients of either gender who may take any other of the dozen or so medications with α-blocking effects associated with IFIS. So, let me reverse this and think about the patients who should not receive the special IFIS precautions. These are techniques incorporated proactively into the surgical procedure that improve the outcome of an individual patient’s result, and certain patients will be excluded from the utility of these precautions because they could not be identified as being at risk for IFIS? These are steps that will admittedly reduce the risk of capsule or iris damage, and some patients won’t be included. Because we were so focused on tamsulosin as the primary risk factor for encountering IFIS, and yet still missing any number of cases, I was providing preferential treatment for patients with benign prostatic hypertrophy. The magnitude of the IFIS issue predicates action to reduce its impact. If the goal is to reduce the complications of this highly sporadic condition, then everyone in my practice should be treated as if they are at risk for IFIS. Everyone: men, with or without prostates; those who remember their medication history, and those who don’t; women, even if they have never heard of a prostate, let alone never had one. Everyone then benefits from the special steps, and they no longer remain “special.” Everyone shares the potential of a better result. The best part is that patients are no longer responsible for influencing their own surgical environment through no fault of their own. My staff has had a tremendous burden taken from them, and the unsuspected IFIS case blends into the background of a normal surgical day. Many of the topics discussed in this chapter to avoid complications associated with IFIS may have no obvious connection to the condition. Rather, this chapter includes many of the changes to the procedure that have taken place in my operating room, either as establishment of best practices or elimination of bad habits. The ultimate goal of these changes is to reduce the impact of the unexpected, unwanted event. IFIS just happened to be the catalyst in taking an organized approach to reducing risks, not just those one can identify in an individual patient. Fig. 23.1 (a) Preoperative tropicamide and phenylephrine were used to achieve a mid-dilated pupil for this patient on tamsulosin. Intracameral dilation is being administered through the side port. (b) A modest amount of dilation and additional tone are achieved with the intracameral solution. Figures 23.4 to 23.9 are video captures from the same case as Figure 23.1. The most obvious issue with IFIS is dilation. It has to be consistent and effective—quality and quantity. At the Pinnacle Surgery Center in Colorado Springs, we have adopted a regimen of spraying the open eye with a compounded formula of one part 1% tropicamide, one part 2.5% phenylephrine, and one part 0.5% ketorolac. The patient opens the eye, and the eye is spritzed (not unlike a fragrance associate at your local cosmetics establishment). The dilation is effective for both femtosecond cataract surgery and standard phacoemulsification (Fig. 23.1a). The surprise about the spritz is that it is effective even with the patient closes the eye. Our original experience with this regimen was with the eye closed. Although that was successful, having the lids open certainly improves the efficacy of the regimen. Comparing this to three different agents delivered as drops 5 minutes apart for three different applications, it really is not surprising that this regimen is preferred by both patients and staff. Is it the size of the pupil or the tone that will help in IFIS cases? Topical atropine starting 3 days prior to surgery was an accepted standard for improving dilation in those pesky miotic pupils. The problems with this approach are twofold. First, to whom is this approach offered? Second, the very patients in whom this regimen will work are those in whom atropine will induce acute urinary retention. (I know of two patients who ended up in the Emergency Department after successful cataract surgery for this very reason. That experience seemed to ruin the otherwise uneventful cataract surgery earlier in the day.) This is a compounded solution of one part 4% nonpreserved lidocaine and one part 1:1,000 epinephrine in three parts balanced salt solution (BSS). Although the preoperative spritz is effective, intracameral dilation appears to substantially increase the iris’s tone (Fig. 23.1b). The advantage of the compounded intracameral formulation is simple: the exact specified concentration of each drug is administered directly to the target tissue. To avoid mixing errors, we do not create this solution on-site. As the solution is clear, it can be passed through a micropore filter under sterile conditions. It does, however, have a limited shelf life, so frequent reordering is necessary. In some patients a small pupil will remain small regardless of the pharmacological manipulations. Only the operating surgeon can determine whether a small pupil is large enough for cataract surgery. Personally, I find that a 3-mm pupil in most cases is large enough, but this is with a highly stable chamber, excellent patient cooperation, a medium-density nucleus, and a specific phaco needle with a rounded edge. But these factors can fall apart at a moment’s notice, requiring another step to regain the pupil dilation. Alternatively, we can infer that a small pupil phaco does not work with an excessively unstable chamber, a patient resistant to immobility, and denser cataracts. One of the most common mistakes in dealing with an IFIS pupil is irritating it. If one intends to use a pupil expansion device, feel free to stretch the pupil to a degree if this will help with placement of the device. If one is trying to obtain a larger pupil without using mechanical support, forget the old teaching about stretching the pupil to enlarge it. Stretching will likely make this worse (Fig. 23.2). In my experience, it does not take much to irritate an IFIS iris. Deliberate iris manipulation in the form of stretching will undoubtedly trigger pupillary miosis. I have personally experienced this with inadvertent engagement of the iris with the phaco needle during insertion, and with the mildest iris prolapse through either the main or side port. Fundamentally, two styles of pupil expansion devices are available: hooks and rings. Hooks are packaged as a set, and the typical deployment uses four to expand the small pupil. Each hook requires a paracentesis port, and the resulting pupil has a diamond configuration. Tom Oetting, MD, in Iowa City, places one of the hooks in the subincisional space to create a good point of access for performing phaco. Hooks are easy to place, and easy to remove. The one problem with using hooks is the potential to stretch a sphincter beyond its capacity to recover. This can result in a postoperative mydriasis that can be both cosmetically and functionally unacceptable. Expanding the pupil to a 6-mm diamond should be well tolerated. Fig. 23.2 The left and right eyes of a patient on Coumadin and tamsulosin. He presented with frustration after a prolonged cataract surgery involving bleeding during surgery. (a) The sphincterotomies are evidence of a surgical manipulation to achieve a larger pupil intraoperatively. The concomitant use of Coumadin only worsened the situation. (b) Using intracameral dilation and viscomydriasis, this pupil remained stable at just under 4 mm despite the tamsulosin use. Rings are the class of expanders that support the pupil size internally. They do not require a paracentesis for external fixation. Several devices are available, and each has advantages and specific insertion techniques. These include the Malyugin ring (MicroSurgical Technologies [MST], Redmond, WA), the Perfect Pupil (Milvella, Savage, MN), the Pupil Dilator (Morcher, Stuttgart, Germany), and the Graether 2000 Pupil Expander (Eagle Vision, Memphis, TN). I have the most experience with the Malyugin ring. The device comes with its own injector, and provides eight points of support. It comes in two sizes, 6.25 and 7 mm, but I have used only the 6.25. It is a single-use device and is inserted and removed with relative ease. Regardless of whether hooks or rings are used, the stage of the surgery will determine the ease of application. Prior to performing the capsulorrhexis, these devices have only the iris to catch upon. Once the capsule is open, greater care should be taken to avoid catching the edge of the capsulorrhexis at the same time as the pupil margin. In cases of dense or leathery nuclei, I use a pupil expansion device with little or no hesitancy. It is difficult to say which of the characteristics of these cases make the iris less well behaved. It could be the additional power, the additional manipulation, the increase in irrigation fluid, or any combination of these factors. In reviewing the videos of these cases, one can see that the pupil almost always ends up smaller, regardless of the initial size (Fig. 23.3). Does the iris billow on its own due to lack of tone, or does it billow due to chamber instability? Probably the easiest way to create an IFIS case is (1) not to use an α-agonist for dilation and (2) create an unstable chamber. Chamber stability begins with a comfortable patient, lying peacefully, not coughing and not moving. For my patients, the first step is Tessalon Perles in the preoperative area. This is 100 mg of sodium benzonatate, and effectively suppresses the cough reflex. It is not perfect, but it is good enough that patients have requested it for home use for the same reason. Two other tricks we use to decrease coughing include punctal occlusion during administration of the topical anesthetic, and a touch of fentanyl when the situation warrants. Regarding the punctal occlusion, it is quite possibly the partial anesthesia of the nasopharynx that stimulates the cough reflex in some patients when assuming the supine position during surgery. The fentanyl is our anesthesia group’s drug of choice, but the group will occasionally use intravenous lidocaine for the recalcitrant cougher. To keep the patient from moving, the anesthesiologist has to be on board with your surgical plan. In an eye center with a dedicated sedation regimen, this is nearly a given. Regardless of the setting or the skill of the anesthesiologist, I highly recommend taping the patient’s head, and strapping the chest and arms. Although the occasional gentle drift is annoying, it will likely cause you to need to remove the instruments from the eye. Once, no problem. Twice, annoying. By the third time, the change in anterior chamber dynamics may be enough to trigger billowing, miosis, or prolapse, even in low-risk patients. The restraint will slow a sudden movement enough to keep a disaster at bay. Using the correct speculum for the situation is the next step. Simple wire specula may be useful for most cases, but pay particular attention to narrow lid fissures. Use a speculum with an active adjustable spreading mechanism. A wire speculum takes up less space in the lid fissure than a closed speculum, and appears to compress the eye less during surgery. Whether the patient is still or not, one often overlooked source of chamber instability is the fit of the incisions. During the crafting of the primary incision, the goals are to have it be both self-sealing and astigmatically neutral, and large enough to avoid binding during the procedure. Given the current size of our incisions (below 2.8 mm), even an imperfect incision will seal well, and induce very little astigmatism.
Which of the following statements best exemplifies your practice?
An Aside
Preoperatively
Intracameral Dilation
Encountering Small Pupils
Pupil Expansion Devices
Chamber Stability
Sizing the Incision
Ento Key
Fastest Otolaryngology & Ophthalmology Insight Engine
