Dec-08 final-output.p65

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.
November 2005.
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 Surv Ophthalmol. 2006 Sep-Oct;51(5):501-12.
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. 2006 Sep;47(9):3766- 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. 2006 Aug;32(8):1336-9.
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. 2005Apr;31(4):664-73.
First Author
Suresh K. Pandey MS
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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