Intraoperative floppy iris syndrome (IFIS) is related to the use of oral alpha 1 antagonist, especially tamsulosin, in patients undergoing cataract surgery. Intraoperative floppy iris syndrome (IFIS) is a complication during cataract surgery that was first reported by Chang and Campbell in the year 2005.
What causes Intraoperative floppy iris syndrome (IFIS) in cataract surgery?
Intraoperative floppy iris syndrome (IFIS) in cataract surgery is associated with α-adrenoceptor antagonists, especially tamsulosin. The factors associated with IFIS have been explored in a comparative case series [ 104c ].
What are the floppy iris syndrome symptoms?
As the name would suggest, floppy iris syndrome symptoms also include an iris that appears floppy or billowing. The occurrence of intraoperative floppy iris syndrome has been linked to patients taking tamsulosin.
What is the prevalence of floppy iris syndrome?
Floppy iris syndrome is not a very common complication of cataract surgery. There is no completely accurate data on the epidemiology of the issue. Studies suggest that between 0.5% and 2% of patients who undergo cataract surgery will experience floppy iris syndrome2.
What is IFIS during cataract surgery?
IFIS is a type of small pupil syndrome, also known as miosis. This is categorized as excessive pupil constriction. Floppy iris syndrome also presents as a billowing iris and iris prolapse. IFIS during cataract surgery can potentially derail the procedure and lead to severe iris damage.
What causes floppy iris syndrome?
Intraoperative floppy iris syndrome (IFIS) was first characterized by Chang and Campbell in 2005. It is associated with the use of systemic α-receptor blockers, such as tamsulosin (Flomax), used in the medical management of benign prostatic hyperplasia (BPH).
How do you treat floppy iris?
The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin.
Can a floppy iris be repaired?
Intraoperative Floppy Iris Syndrome Treatment When ophthalmological surgeons encounter IFIS during a cataracts surgery, they have a few best practices for treatment. These include expansion rings and iris hooks/retractors. If used correctly, iris hooks offer a mechanical method for reversing miosis.
Does Floppy iris affect vision?
The iris can also slip out of its normal position during surgery, making it even harder for the ophthalmologist to remove the old lens and insert a new one. This condition, dubbed floppy iris syndrome, increases the chance of complications, including vision loss.
Is Floppy Iris Syndrome serious?
Purpose of review. Intraoperative floppy iris syndrome (IFIS) occurs in 2% of cataract surgeries and is associated with an increased risk of surgical complications. These complications can be avoided when high-risk patients are identified by preoperative screening and appropriate measures are used intraoperatively.
What drugs cause floppy iris syndrome?
The list of drugs associated with intraoperative floppy iris syndrome:Alfuzosin.Chlorpromazine.Donepezil.Doxazosin.Finasteride.Labetolol Hydrochloride.Mianserin.Prazosin.More items...•
Is Floppy Iris Syndrome permanent?
At least for tamsulosin, IFIS has still been observed in patients who discontinued therapy as long as nine months or even three years before cataract surgery. The persistence of IFIS several months after stopping tamsulosin implies that the atrophic iris changes resulting in an atonic pupil are probably permanent.
How can intraoperative floppy iris be prevented?
IFIS can be prevented and treated by maintaining mydriasis and restraining the iris from prolapsing during cataract surgery. This can be accomplished by mechanical and pharmacologic treatments and the use of intraoperative proper phacoemulsification fluidic parameters.
What medications should be stopped before cataract surgery?
1. MEDICATIONS To minimize the risk of blood loss during your surgery, you must avoid or stop taking medications that contain aspirin, that are anti-inflammatory medications, or contain blood thinning agents. These should be discontinued 7-10 days prior to your surgery.
Do I have to take Flomax forever?
For enlarged prostate – if tamsulosin is helping your symptoms, you can continue to take it long term. Your doctor may check every few months that you're still having relief from symptoms. For kidney stones – your doctor may tell you to stop taking it if your stones have gone or if the medicine is not helping you.
What are the long term effects of taking tamsulosin?
Tamsulosin side effects long term The researchers found that some of the most common adverse effects included infection, accidental injury, runny nose, pain, and sore throat; other reported side effects included abnormal ejaculation, syncope, and orthostatic hypotension (Narayan, 2005).
What medication is given for cataract surgery?
The three primary classes of medications used around the time of cataract surgery are antibiotics, corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Within these classes, there are multiple medications from which to choose, including generics.
Is Floppy iris Syndrome permanent?
At least for tamsulosin, IFIS has still been observed in patients who discontinued therapy as long as nine months or even three years before cataract surgery. The persistence of IFIS several months after stopping tamsulosin implies that the atrophic iris changes resulting in an atonic pupil are probably permanent.
How do you prevent iris prolapse?
An accompanying article will discuss the history of iris prolapse as well as several mechanical and fluid dynamics-based theories believed to contribute to iris prolapse.Create a "longer" wound. ... Avoid overfilling the anterior chamber with viscoelastic. ... Remove viscoelastic before hydrodissection.More items...
What happens when iris is damaged?
Patients with aniridia or damaged irises can suffer from severe light sensitivity and are often unhappy with the appearance of their eyes. Also, a damaged iris admitting too much light can result in reduced vision, halo and glare. Treatment options include sutures and artificial iris implantation.
What is Iridodialysis?
Iridodialysis is the disinsertion of the iris from the scleral spur. It is in contrast from cyclodialysis, which is disinsertion of the ciliary body from the scleral spur. This patient suffers from monocular diplopia and glare.
What is IFIS in surgery?
Intraoperative floppy iris syndrome ( IFIS) is a complication that may occur during cataract extraction in certain patients. This syndrome is characterized by a flaccid iris which billows in response to ordinary intraocular fluid currents, a propensity for this floppy iris to prolapse towards the area of cataract extraction during surgery, and progressive intraoperative pupil constriction despite standard procedures to prevent this.
What is the best treatment for IFIS?
Tamsulosin is a selective alpha blocker that works by relaxing the bladder and prostatic smooth muscle. As such, it also relaxes the iris dilator muscle by binding to its postsynaptic nerve endings. Various alpha-blockers are associated with IFIS, but tamsulosin has a stronger association than the others.
Does IFIS cause postoperative pain?
IFIS does not usually cause significant changes in postoperative outcomes. Patients may experience more pain, a longer recovery period, and less improvement in visual acuity than a patient with an uncomplicated cataract removal.
Does IFIS cause cataracts?
The medication is also associated with cataract formation. IFIS may also be associated with other causes of small pupil like synechiae, pseudoexfoliation and other medications (used for conditions such as glaucoma, diabetes and high blood pressure ).
What is Intraoperative Floppy Iris Syndrome?
Intraoperative floppy iris syndrome is a condition that may occur during ophthalmological surgery. IFIS is defined by certain criteria, including iris shrinkage and iris prolapse at the surgical site. As the name would suggest, floppy iris syndrome symptoms also include an iris that appears floppy or billowing.
How to treat iris prolapse?
Clinicians also have options to treat iris prolapse post-surgery. Most important for prolapse reversal is a watertight seal on the wound. Another crucial step is administering Miochol, a chemical solution that causes the pupil to contract.
What are the best practices for IFIS?
These include expansion rings and iris hooks/retractors. If used correctly, iris hooks offer a mechanical method for reversing miosis. Further, hooks and retractors can help prevent iris prolapse during surgery.
Can Iris hooks be used for cataract surgery?
Surgeons must remain vigilant for signs of IFIS over the course of cataracts surgery. However, the tools and methods for treatment also present operational risks. Iris hooks and retractors can be effective interventions for IFIS. But they can also cause serious iris trauma (excessive stretching or manipulation) if implemented incorrectly.
How to prevent iris prolapse during hydrodissection?
Attempts should be made to ensure decreased irrigation and aspiration flow rates and direct irrigation currents above the iris plane and away from the pupillary margin to reduce the degree of anterior displacement of the lens–iris diaphragm, preventing the iris from prolapsing. In the presence of iris prolapsing tendency, it has been suggested to bowl out a small portion of central endonucleus, followed by hydrodelineation from inside-out, resulting in an ability to rotate the endonucleus and then chop the residual endonuclear bowl in the usual manner.
What is IFIS in surgery?
Intraoperative floppy iris syndrome (IFIS) is a clinical entity originally described by Chang and Campbell in 2005. This syndrome is known to cause a poor pupillary dilation, intraoperative complications during cataract surgery and is characterized by the following triad of intraoperative signs:
What is the purpose of OVR in IFIS?
This cohesive OVR has the ability to dilate the small pupil effectively and also to create a physical barrier to decrease iris billowing and prolapse through the incisions. However, the latter effect depends on Healon5 to remain in the anterior chamber throughout the procedure, which requires measures like the use of low aspiration flow and vacuum settings. If high vacuum settings are needed (e.g. dense nucleus), a dispersive OVR may be injected peripherally, followed by central injection of Healon5, so the former remains in the anterior chamber closer to the cornea and provides stability of intraoperative mydriasis – this technique is known as modified soft-shell technique.
What is the most likely pathogenic mechanism for IFIS?
The most likely pathogenic mechanism for IFIS is the antagonism of α 1-adrenergic receptors within the dilator muscle of the iris, which prevent the iris from dilation during surgery. This inhibition can happen with the use of some types of medications, such as the most commonly prescribed α 1-adrenegic receptor antagonist ( α 1-ARA) tamsulosin used for the management of benign prostatic hyperplasia (BPH).
Why does IFIS increase with age?
The risk for IFIS may increase with aging due to iris vasculature dysfunction and altered potency of norepinephrine in iris dilator muscles (which is proportional to receptor reserve).
How prevalent is IFIS?
The reported overall prevalence of IFIS in patients undergoing phacoemulsification is variable, ranging from 2% in the Chang and Campbell report in 2005, up to 12.6% in later studies. This wide range of prevalence might be due to the subjective clinical definition of this syndrome and its manifestations being a continuum of severity with variability between patients and between eyes of the same patient. The prevalence also varies among countries and is significantly increased in groups of patients with clinical factors positively correlated with IFIS.
Why is it important to use pupil expansion devices?
Therefore, it is important to anticipate IFIS and use pupil expansion devices as a preventive measure in the beginning of surgery rather than after IFIS has developed and the capsulorrhexis is already completed (which might compromise its integrity).
What Are The Symptoms Of Floppy Iris Syndrome?
Floppy iris syndrome is a complication that generally happens during cataract surgery. For this reason, the patient may not notice symptoms right away. Instead, the surgeons responsible for the cataract removal are the ones who may notice the complication.
What is the cause of floppy iris?
The use of tamsulosin is considered a significant cause behind floppy iris syndrome. Studies show up to 87% of patients with the syndrome took tamsulosin in the past. This is a drug commonly used to treat enlarged prostate in men .
What is a thorough assessment of floppy iris syndrome?
A thorough assessment of the floppy iris syndrome will be required. The surgeon will be able to see exactly how the iris dysfunction has affected the eye through such an examination. An appropriate treatment plan needs to be developed in this scenario. The treatment plan will be based on the surgeon’s findings.
How many people have floppy iris after cataract surgery?
Studies suggest that between 0.5% and 2% of patients who undergo cataract surgery will experience floppy iris syndrome2. In the majority of cases, floppy iris syndrome is linked to the use of certain medications.
Why is my iris billowing?
Flaccid iris billowing happens when a patient develops floppy iris syndrome.
Does tamsulosin cause floppy iris?
This helps them determine how likely they might be to develop the complication during a cataract-removal surgery. The use of tamsulosin is considered a significant cause behind floppy iris syndrome. Studies show up to 87% of patients with the syndrome took tamsulosin in the past.
Is floppy iris more common in men or women?
In fact, research has shown that men are about nine times more likely to develop floppy iris syndrome than women. It is still important to note that some BPH drugs are used in women with urinary symptoms. When this is the case, the female patient still experiences a higher risk for floppy iris syndrome.
How to manage billowing iris?
Low fluidics. The use of less aggressive irrigation and aspiration is a logical step in managing a billowing iris. Surgeons have reported greatest success with simply reducing the fluidics parameters on the phaco machines by 10 to 15 percent (e.g., lowering bottle height from 95 cm to 84 cm). Newer phaco machines feature automated settings for use in IFIS patients. James P. Gills, MD, recently developed a single-port phaco tip that is expected to reduce turbulence in the anterior chamber. Up to 95 percent of IFIS cases have been reported as successfully managed when low fluidics were used in combination with a viscoadaptive ophthalmic viscosurgical device such as Healon 5. A note of caution about Healon 5: It may cause postoperative pressure spikes if not removed completely.
Why do surgeons use Trypan blue?
Trypan blue helps the surgeon view and stay clear of the rim of the capsulorhexis if the pupil becomes miotic or other signs of IFIS occur during phacoemulsification. Trypan blue also helps the surgeon view areas of the capsule not well exposed by iris hooks.
Does flomax cause vitreous loss?
One retrospective study performed before IFIS was described in 2005 showed that Flo max patients had significantly greater complication rates than controls. Vitreous loss rates as high as 70 percent were reported. In contrast, a landmark multicenter study by The Tamsulosin Study Group in 2007 established that prior knowledge of the patient’s drug history significantly reduced the risk of complications by allowing the surgeon to intervene at the appropriate time.
Can iris retractors cause pupil constriction?
However, since there is no risk of midprocedure pupil constriction with iris retractors, they are appropriate in patients who have already demonstrated poor dilation in the clinic or before surgery. When used, the retractors may be arranged in a diamond configuration for greatest effectiveness. Retractor rings.
Is atropine good for pupil dilation?
For instance, the Tamsulosin Study Group reported that more than half its study patients needed another form of intervention after atropine usage. Atropine provides excellent preoperative pupil dilation but is not as good at controlling pupil size during phacoemulsification.
Does flomax cause IFIS?
Why Flomax? The reason why Flomax can cause IFIS is the same as the reason for its mechanism of action for treating BPH: Flomax relaxes the smooth muscle of the bladder neck—and, inadvertently, the iris dilator as well—by specifically targeting the alpha 1A receptors. Its specificity significantly reduces the postural hypotension that is common to nonselective alpha blockers used to treat BPH. The blockade of this receptor subtype, however, renders ineffective the conventional dilator drops used in cataract surgery. There have been cases in which a mere two weeks of Flomax therapy led to IFIS. While Flomax is not the only drug implicated, it is by far the most common. But many studies have shown a statistically increased risk of IFIS among users of other alpha 1 blockers, such as terazosin (Hytrin) and alfuzosin (Uroxatral), which are used to relieve symptoms of BPH. Doxazosin (Cardura), used to treat systemic hypertension as well as BPH, also falls in this category.
What is IFIS in a cataract?
In 2005, John Campbell and I first described a new small pupil syndrome that we named intraoperative floppy iris syndrome (IFIS) ( J Cataract Refract Surg. 2005;31:664-673). Classic IFIS manifests as a triad of intraoperative signs beyond poor pupil dilation: iris billowing and floppiness; iris prolapse to the main and side incisions; and progressive miosis (Figure 1). Particularly if such iris behavior is unexpected, the rate of complications such as posterior capsule rupture, vitreous loss, and iris trauma is increased. We first reported IFIS as being highly associated with the use of tamsulosin (Flomax), a systemic alpha-1 antagonist and the most widely prescribed treatment worldwide for benign prostatic hyperplasia (BPH). Since then, it has become clear that other systemic alpha-1 blockers such as doxazosin (Cardura), terazosin (Hytrin), and alfuzosin (Uroxatral) can also cause IFIS. Nevertheless, the frequency and severity of IFIS is much less with these nonspecific alpha-1 antagonists than with tamsulosin. This difference probably relates to the much stronger affinity and specificity of tamsulosin for the alpha-1A receptor subtype that predominates in both the prostate and the iris dilator muscle. 2,3
How to expand pupil in IFIS?
Iris retractors are the other mechanical strategy for pupil expansion in IFIS. Placement of the hooks in a diamond configuration (Figure 5) has several significant advantages ( J Cataract Refract Surg. 2002;28:596-598). The subincisional hook retracts the iris downward and out of the path of the phaco tip. This maximizes exposure in front of the phaco tip, while the nasal hook facilitates chopper placement. One-millimeter limbal paracenteses are made in each quadrant including a separate stab incision made just posterior to the temporal clear corneal incision. In this way, the subincisional hook and the phaco probe occupy separate entry tracks. If the pupil is fibrotic, overstretching it with iris retractors can cause bleeding, sphincter tears, and permanent mydriasis. This typically does not occur with the IFIS pupil, though, because it is so elastic that it readily springs back to physiologic size despite being maximally stretched. Options include 6-0 nylon disposable retractors or reusable 4-0 polypropylene retractors. The latter are the same size and rigidity as an intraocular lens (IOL) haptic, so they are more easily manipulated and can be repeatedly autoclaved, making them more cost effective to use.
How to treat IFIS?
Direct intracameral injection of alpha agonists is an excellent pharmacologic strategy for IFIS. The use of phenylephrine to prevent IFIS was first reported by Packard (Eye. 2007;21:331-332) as was epinephrine by Shugar ( J Cataract Refract Surg. 2006;32:1074-1075). By presumably saturating the alpha-1A receptors, these agents can further dilate the pupil and restore iris rigidity, thus increasing the iris dilator smooth muscle tone (Figure 2). By increasing iris rigidity, billowing and prolapse are often prevented. Preserved solutions should be avoided, however, and one must use a diluted mixture (e.g., 1:1000 bisulfite-free epinephrine [American Regent] mixed 1:3 with balanced salt solution [BSS] or BSS+) in order to buffer the acidic pH of the commercial preparation.
What is IFIS severity?
IFIS can be classified as mild (i.e., good dilation; some iris billowing without prolapse or constriction), moderate (i.e., iris billowing with some constriction of a moderately dilated pupil), or severe (i.e., classic triad and poor preoperative dilation). In one prospective study of 167 eyes in patients taking tamsulosin, the distribution of IFIS severity using this scale was as follows: no IFIS (10%), mild (17%), moderate (30%), and severe (43%) (Ophthalmology. In press). Because there is significant variability in IFIS severity among various patients and even between two eyes of the same patient, it is difficult to conclude whether one management strategy is superior to another. In fact, because the various IFIS techniques discussed in this article can be combined, physicians would do well to master several complimentary approaches.
