Intraoperative Floppy Iris Syndrome (IFIS)
Suresh K. Pandey MS, Vidushi Sharma MD, FRCS
Intraoperative Floppy Iris Syndrome or IFIS was first described IFIS. The various
antagonist drugs are available in India under the
in 2005 by Chang and Campbell, as a clinical triad observed
during cataract surgery, that includes fluttering and billowing of theiris stroma, propensity for iris prolapse, and progressive
Dynapres / Urimax/ Veltam (Tamsulosin) by Dr. Reddy’s labs,
intraoperative constriction of the pupil. IFIS increases the risk of
serious complications during cataract surgery and makes the surgery
much more difficult for the surgeon. It was first reported inassociation with the use of tamsulosin, which is an α -adrenergic
receptor ( AR) antagonist used in the treatment of benign prostatic
hypertrophy. Since then, many cataract surgeons from all over theworld have reviewed their own patients taking this drug and found
Risperidone (antipsychotic) by RPG life Sciences
the same association during cataract surgery.
Prospective evaluation of viscomydriasis using healon-5®) and
flexible iris hooks
Characteristically, the pupil dilates poorly in response to the routine
We prospectively evaluated use of Healon-5®) and flexible iris hooks
preoperative mydriatics, or starts to constrict soon after the first
during phaco surgery in male patients taking Tamsulosin
incision; the iris tends to prolapse despite well-constructed incisions,
Hydrochloride for treatment of benign prostates hyperplasia (BPH)
and the iris stroma can be seen to be fluttering excessively in
that predisposed them to IFIS. Cataract cases operated at the our
response to normal intraocular fluid currents during surgery. All
centre during past 2 years with systemic history Tamsulosin
routine attempts to dilate the pupil are usually ineffective and the
(Dynapres, Dr Reddy’s Laboratories; Urimax, Cipla, Veltam- Intas)
pupil progressively constricts further, making the surgery more
were randomized as use of sodium hyaluronate 2.3%, (Healon-5®)
to achieve intraoperative dilatation of small pupil in the one eye ofall cases or use of flexible iris hooks to expand the pupil for fellow
(contralateral) eyes of all cases. Results of this study suggested that
While the exact cause for this syndrome is still not clear, it has been
out of 600 total cataract cases, 12 patients (2%) have had history of
postulated that the AR antagonists cause relaxation of the
systemic intake of Tamsulosin. Viscomydriasis achieved by injection
iris dilator muscle and cause disuse atrophy of this muscle in the
of (Healon-5®) provided satisfactory pupil dilatation to commence
long-term. It has been estimated that up to 2% of cataract surgery
the surgery. However, a tendency of progressive constriction of
patients may be taking tamsulosin as cataract and BPH often co-
pupil, was noted during the nuclear emulsification and irrigation/
exist in the same elderly population. In a postal survey of UK
aspiration, which necessitated repeated injection of the Healon-
cataract surgeons, 53% surgeons had encountered the syndrome
5®. Posterior capsule rupture occurred during chopping of a dense
either retrospectively or prospectively in male and female patients
cataract using high vacuum and high flow rate in one eye. The
on tamsulosin as well as other alpha-receptor antagonists.
flexible iris hooks maintained a satisfactory pupil size the procedure.
Although 68% of consultants had patients discontinue taking
There was no intraoperative complication in any eye where these
tamsulosin preoperatively, they reported no consistent benefit
hooks were used for mechanical enlargement of pupil. Results of
from this step. In a similar online survey of members of the
this pilot study suggests that operating IFIS cases using Healon 5® is
American Society of Cataract and Refractive Surgery, 95% believed
more dependent upon fluidic parameters, surgical technique as
that tamsulosin makes cataract surgery more difficult and 77%
well as surgeon’s experience. The flexible iris hooks are helpful for
believed it increases the risks of surgery. Commonly reported
mechanical pupil enlargement and for protection of the pupil margin
complications of IFIS were significant iris trauma and posterior
Systemic medications associated with IFIS
The management of this condition begins by anticipating the
Tamsulosin is a selective alpha-1A receptor subtype antagonist,
syndrome preoperatively by taking a careful history of drug use in
while other non-specific receptor antagonists, including terazosin,
all cataract surgery patients. If the pupil does not dilate
doxazosin, and alfuzosin, have also been linked to IFIS; however,
preoperatively, atropine may be used, but is usually not very effective.
their relationship to the syndrome is not as definitive. Similarly, an
It is important for surgeons to pay attention to achieve a proper
anti-psychotic drug, risperidone has also been implicated to cause
wound construction, excessive hydrodissection and excessiveinjection of viscoelastic injection should be avoided.
Flexible Iris Retractors:
It is better to anticipate the problem andplace iris retractors at the outset, and this is one of the best methods
Suvi Eye Hospital & Research Centre
for managing this condition.
Multiple sphincterotomies and
A 475 Indra Vihar, Near Shiv Jyoti School,
pupillary stretching is not only ineffective, it may actually increase
the propensity for iris prolapse and fluttering by decreasing the iris
Pandey SK, Milverton EJ.
The Prospective use of Perfect Pupil
tone further. This distinguishes IFIS from other causes of small
Injectable for Cataract surgery in patients on Flomax. Presented at
pupil, where pupillary stretching is effective as the pupillary margins
American Academy of Ophthalmology. New Orleans, LA, USA,
are fibrotic unlike the floppy, atonic iris seen in IFIS.
Schwinn DA, Afshari NA. “alpha(1)-Adrenergic receptor antagonists
Pupil expansion rings (e.g. PerfectPupil, Milvella Pty Ltd., Sydney,
and the iris: new mechanistic insights into floppy iris syndrome.”
Australia) are helpful for pupil expansion and well as for protection
of prolapse iris tissue to come in contact with phaco probe and/orduring irrigation/aspiration.
Parssinen O, Leppanen E, Keski-Rahkonen P, Mauriala T, Dugue B,Lehtonen M. “Influence of tamsulosin on the iris and its implications
Viscoadaptive Viscoelastic- sodium hyaluronate 2.3%, (Healon-5®):
for cataract surgery.” Invest Ophthalmol Vis Sci.
The use of viscoelastics like Healon-5®)
has also been shown to be
effective in dilating the pupil, though it needs to be replenished
Cheung CM, Awan MA, Sandramouli S. “Prevalence and clinical
constantly. Slow motion phaco is certainly a help in minimizing
findings of tamsulosin-associated intraoperative floppy-iris syndrome.”
intraocular fluid currents. The use of intracameral phenylephrine
J Cataract Refract Surg.
or epinephrine is useful in many cases, to dilate the pupil thoughiris prolapse still remains a challenge.
Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, NichaminLD, Packard RB, Packer M; ASCRS Cataract Clinical Committee.
Clinical experience with intraoperative floppy-iris syndrome. Resultsof the 2008 ASCRS member survey. J Cataract Refract Surg.
To conclude, IFIS is increasingly being recognized with the use of
many kinds of systemic medications used to manage BPH. Recently,
Chadha V, Borooah S, Tey A, et al. Floppy Iris Behaviour During
anti-psychotic drugs (e.g. risperidone) has also been implicated to
Cataract Surgery: Associations and Variations. Br J Ophthalmol. 2007;
cause IFIS. While these complications were observed by surgeons
even before the discovery of this syndrome, now we can anticipatethe problem by taking a careful medical history of using tamsulosin
Oshika T, Ohashi Y, Inamura M, et al. Incidence of intraoperative
hydrochloride and other medications in all elderly patients and be
floppy iris syndrome in patients on either systemic or topical alpha
prepared for managing patients identified to be at risk for having
(1)-adrenoceptor antagonist. Am. J. Ophthalmol 2007; 143:150-151.
IFIS. The flexible iris hooks are helpful for mechanical pupil
Pandey SK, Sharma V. Prospective evaluation of viscomydriasis using
enlargement and for protection of the pupil margin in IFIS. It is also
Healon-5®) and flexible iris hooks for phaco surgery in patients on
important for surgeons to pay attention to achieve a proper wound
tamsulosin hydrochloride. Accepted for presentation, AIOS
construction, excessive hydrodissection and excessive injection of
ophthalmic viscoelastic agents should be avoided. A well-managedIFIS does not usually cause significant changes in postoperativeoutcomes.
Chang DF, Campbell JR. “Intraoperative floppy iris syndromeassociated with tamsulosin.” J Cataract Refract Surg.
Suresh K. Pandey
Heartfelt Congratulations to Dr. Namrata Sharma, Dr. Vishal Jhanji, Prof. J.S. Titiyal, Prof. R.B. Vajpayeefor winning the best video titled, “Deep Anterior Lamellar Keratoplasty by Big Bubble Technique in
Hurler-Scheie Syndrome” in the Refractive/Cornea category at Asia Pacific Association of Cataract &Refractive Surgeons held in Bangkok, Dec 2008.
DOS Times - Vol. 14, No. 6, December 2008
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Useful Prescriptions for Common Oral Diseases: 2013 John R. Kalmar, DMD, PhD The Ohio State University College of Dentistry The following are examples of prescriptions for medications used in treating the common oral disorders. Cost information, as provided by the OSU Wexner Medical Center Walgreen’s pharmacy, is for comparison purposes only. Pricing and availability will vary. Herp