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Cover Stories | Apr 2010

Intraoperative Floppy Iris Syndrome

A systematic approach.

Samuel Masket, MD

Intraoperative floppy iris syndrome (IFIS) has  been well defined by Chang and Campbell and  is characterized by poor dilation of the pupil,  intraoperative progressive miosis, billowing of  the iris tissue, and iris prolapse through the  ocular incisions during cataract surgery.1 IFIS has been  associated with increased rates of surgical complications,  including capsular rupture, vitreous loss, and the loss of  iris tissue. Induced primarily by the alpha 1-a inhibitor,  tamsulosin (Flomax; Boehringer Ingelheim Pharmaceuticals,  Inc.), IFIS may be associated with other alphablockers,  psychotropic drugs, and over-the-counter  agents such as saw palmetto. Tamsulosin is considerably  more likely to induce IFIS than are other medications.

A number of surgical strategies can reduce the complication  rates associated with IFIS and make cataract surgery  similar to routine cases.2 Extensive experience with  patients using tamsulosin led me to develop a stepwise  approach to management, which I use routinely for individuals  with a history of therapy with this drug.

  It is essential to be aware of a patient’s use of tamsulosin.  Obtaining an accurate history may be difficult,  however, because some individuals (typically men, in my  experience) are reluctant to divulge a history of any genitourinary  condition, particularly to a female staff member.  Moreover, patients may only report medications they  are currently taking, but past exposure to tamsulosin can  have lingering effects.

In my practice, our protocol is to ask patients about  any exposure to tamsulosin at any time. Cataract surgery  patients are queried on several occasions—generally,  when surgery is scheduled, when surgery is confirmed,  when they arrive at the surgery center, and when they  are interviewed by the circulating nurses and anesthesia  personnel.

  Without a doubt, the   key to success in the potential  IFIS case is a widely dilated pupil. During the office visit, I  carefully evaluate and record how the patient’s pupil  dilates in response to mydriatics/cycloplegics. A wide  pupil in response to weak dilating agents confers an  excellent surgical prognosis. Conversely, poor dilation in  the office suggests that surgery could be challenging; I  know to allow for greater-than-average procedural time  and to be prepared to use additional surgical tools.

  A poorly dilating pupil is associated with a   greater  chance of capsular rupture in routine cataract surgery. In  eyes with IFIS, irrigating fluid may pass beneath the iris  and induce it to billow and possibly prolapse. A widely  dilated pupil will allow the irrigating fluid to remain  above the iris plane, thereby reducing the manifestations  of IFIS. The chief purpose of atropine is to prevent progressive  intraoperative miosis. As the strongest pupilloplegic  agent, it offers the best chance of preventing the  pupil’s progressive constriction during surgery. Atropine  must be administered well in advance of surgery, however,  because considerable time is necessary to realize its  full effect. As a result, I have patients instill the drop three  times daily for 2 full days prior to surgery. For example, a  patient scheduled to have surgery on Tuesday will begin  using the medication on Sunday. Patients are also  instructed to continue their tamsulosin therapy, due to  the risk of acute urinary retention with the use of  atropine.

As I have previously published, the synergism between  topical atropine and intraocular epinephrine (to be discussed  further) is very successful in eyes with IFIS, but the  strategy requires that the surgeon be aware of the  patient’s history and that he or she initiate atropine well  in advance of surgery.3

  Given the proclivity of the iris to prolapse as a manifestation  of IFIS, the surgeon should take care to construct  incisions that have long tunnels. A square surface configuration  offers the best protection for both the main incisions  and paracenteses.

  The late Joel Shugar, MD, reported a benefit to the  direct stimulation of the iris dilator muscle by intracameral  epinephrine as another pharmacologic method to eliminate  or reduce the signs of IFIS.4 My experience, however,  dictates that epinephrine or atropine alone is not as useful  as their use in combination. Direct stimulation of the  iris dilator muscle from epinephrine together with nearly  absolute pupilloplegia allows me to perform routine  cataract surgery for well above 90% of tamsulosin users.

My initial approach was to administer 1:4000 epinephrine  beneath the iris at the outset of surgery.3 Recently, I  determined that I achieve an equal effect with a combination  of unpreserved lidocaine 1% and unpreserved,  bisulfite-free epinephrine 1:100,000 in final dilution. I  employ this mixture in routine cataract surgery for intraoperative  pupillary dilation, and I combine it with presurgical  topical atropine for IFIS prevention (Figure 1).

  In addition to the pharmacologic strategies   already  described, retentive ophthalmic viscosurgical devices  (OVDs) can mechanically help maintain a dilated pupil.  High-viscosity OVDs can apply pressure to the anterior

surface of the iris and create so-called viscomydriasis. In  the United States, I find the two best-suited agents for  this purpose are Healon5 (Abbott Medical Optics Inc.,  Santa Ana, CA) and DisCoVisc (Alcon Laboratories, Inc.,  Fort Worth, TX). These OVDs differ in their rheology, so  surgeons should become familiar with their use in routine  situations before applying this strategy for IFIS. For  example, it is necessary to add Healon5 to the anterior  chamber multiple times during phacoemulsification, and  the surgeon may need to reduce fluidic turnover by  modifying the vacuum and flow settings.

  It is important to avoid irrigating large volumes of balanced  salt solution infusate under the iris, as this will  increase the likelihood that the tissue will billow and prolapse,  particularly with poor pupillary dilation. In this situation,  the surgeon may consider reducing the height of  the infusing bottle during disassembly of the nucleus.  After nuclear division, the surgeon should bring the pieces  anterior to or into the plane of the iris for removal, while  allowing the infusion to be directed anterior to the iris. At  this juncture, the bottle height can be raised to routine  levels, as long as the infusion is anterior to the iris.

An alternative strategy for nuclear removal in IFIS   cases  is to prolapse one pole of the nucleus anteriorly, assuming  adequate chamber depth and corneal endothelial  health (Figure 2). In this manner, the infusion of balanced  salt solution will be directed anterior, rather than posterior,  to the iris diaphragm.

  In my experience, the strategies described have been  successful for the great majority of potential IFIS patients.   Occasionally, however, the pupil may fail to dilate beyond  the edge of the planned capsulorhexis, which can foreshadow  difficulty during phacoemulsification. In such  cases, I find that it is safest to employ mechanical iris  retraction. Although a number of tools are available for  that purpose, I have had experience and excellent results  with both standard iris retractors (Figure 3) and the  Malyugin Ring (MicroSurgical Technology, Redmond,  WA) (Figure 4). These devices slightly lengthen surgery  and variably increase its expense, but the complications  that their use prevents make them more than worthwhile.

  In potential IFIS eyes, a logical approach allows the surgeon  to take advantage of the available pharmacologic,  fluidic, and mechanical strategies that all contribute to a  successful outcome. The one unifying element is adequate  pupillary dilation.

Samuel Masket, MD, is a clinical professor at the   David  Geffen School of Medicine,UCLA, and is in private practice  in Los Angeles. He is a consultant to, is on the speakers’  bureau of, and has received grants/research support from  Alcon Laboratories, Inc. Dr. Masket may be reached at  (310) 229-1220; avcmasket@aol.com.

  2. Chang DF,Campbell JR.Intraoperative floppy-iris   syndrome associated with tamsulosin.J Cataract Refract Surg.  2005;31:664-673.
  4. Chang DF,Osher RH,Wang L,Koch DD.Prospective   multi-center evaluation of cataract surgery in patients taking  tamsulosin (Flomax).Ophthalmology.2007;114:957-964.
  6. Masket S,Belani S.Combined preoperative   topical atropine sulfate 1% and intracameral nonpreserved epinephrine  hydrochloride 1:4000 (corrected) for management of intraoperative   floppy-iris syndrome.J Cataract Refract  Surg.2007;33:580-582.
  8. Shugar JK.Prophylaxis for IFIS [letter].J   Cataract Refract Surg. 2007;33:942-943.

David F. Chang, MD

Five years after intraoperative floppy iris syndrome  (IFIS) was first described,1 there is still  no clear preference among ophthalmologists  for the surgical management of these cases,  according to a survey conducted in 2008 by  the ASCRS Cataract Clinical Committee.2 In fact, when  asked to name their preferred single method for IFIS, the  most common response (33%) was “always employ multiple  strategies” (Figure 1).

One reason for the diversity of opinions and   approaches  is the variable range of IFIS’ severity. A prospective multicenter  study of cataract surgery in 167 consecutive eyes of  patients on tamsulosin rated IFIS as mild (billowing only),  moderate (billowing and intraoperative miosis), or severe  (billowing, miosis, and iris prolapse).3 Using this   classification,  10% of the tamsulosin cases had no IFIS, 17% had mild  IFIS, 30% had moderate IFIS, and 43% had severe IFIS. In general,  I anticipate severe IFIS when the patient is taking tamsulosin and the   pupil dilates poorly preoperatively. Another  warning sign is billowing of the iris immediately upon the  instillation of intracameral lidocaine. In contrast, if the pupil  dilates well preoperatively, I expect mild-to-moderate IFIS,  but I am still prepared for iris prolapse. Patients taking nonselective  alpha-1 antagonists or who have  stopped their alpha blockers for several  months are most likely to display mild-tomoderate  IFIS.

Considering the variable severity of IFIS,  it makes sense that certain strategies, such  as pharmacologic approaches, may work  well in some eyes but poorly in others.2,4  Clearly, it is to surgeons’ advantage to be  familiar with several different strategies  from which they may select according to  the situation or that they may use in combination  to achieve complementary benefits.  Intracameral alpha agonists, such as  epinephrine, illustrate this point well. In  some eyes, injecting epinephrine results in  significant mydriasis and rigidity of the iris,  whereas it has little effect on pupillary size  or billowing or prolapse of the iris in other eyes.

  Using intracameral   epinephrine is both safe and inexpensive,  and if the pupil dilates moderately well, I routinely inject this agent   prior to initiating the capsulorhexis. It  may take a minute before the pupil slowly dilates, but even  if it does not, the alpha agonist will often increase tone in  the iris dilator muscle, thereby reducing billowing and the  tendency for prolapse or further miosis. A 1:4000 epinephrine  solution is made by adding 0.2 mL of commercially  available 1:1000 epinephrine to 0.6 mL of plain balanced salt  solution in a 3-mL disposable syringe. The late Joel  Shugar, MD, determined that this dilution raised the acidic  pH of the stock epinephrine solution to physiologic levels,  and I have used this formulation more than 200 times without  evidence of endothelial toxicity.5 American Regent, Inc.  (Shirley, NY), and Cura Pharmaceutical Co., Inc. (Eatontown,  NJ), produce a bisulfite-free epinephrine solution.

If mydriasis remains borderline adequate after the   injection  of epinephrine, Healon5 (Abbott Medical Optics Inc.,  Santa Ana, CA) can then be used to mechanically expand  the pupil further.6 Viscomydriasis facilitates the capsulorhexis  and combines with the epinephrine-induced iris  rigidity to block iris prolapse. Keeping the aspiration vacuum  and flow rate to a minimum prolongs the presence of  Healon5 in the anterior chamber, as does the strategy from  Wendell Scott, MD, of adding a dispersive ophthalmic viscosurgical  device over the lens to displace the Healon5  peripherally and delay its aspiration.

When the pupil dilates poorly preoperatively (eg, 3 to  5 mm in diameter), I have found it easiest to proceed  directly to mechanical devices, which are more difficult to  insert following the creation of the capsulorhexis. Both iris  retractors and the Malyugin Ring (MicroSurgical  Technology, Redmond, WA) provide 100% assurance that  the pupil will be adequately large and will not constrict during   surgery. These devices also allow surgeons to use  their routine ophthalmic viscosurgical device, phaco technique,  and fluidic parameters. For example, I would rather  not give up the higher vacuum and flow parameters that I  prefer for dense nuclei. This guarantee of adequate pupillary  diameter and control is helpful in the presence of other  risk factors such as pseudoexfoliation, weak zonules, brunescent  nuclei, or a poor red reflex. Other issues to consider  are the individual surgeon’s level of confidence with small  pupils or with functionally one-eyed patients.

Iris retractors should be placed in a diamond   configuration,  as described by Oetting and Omphroy7 (Figure 2). The  subincisional retractor occupies a separate paracentesis tract  that is located just posterior to the temporal clear corneal  incision. Because it pulls the iris down and behind the phaco  tip, this configuration provides excellent access to subincisional  cortex and avoids tenting the iris up in front of the  phaco tip, as occurs with a square configuration of retractors.  The nasal iris retractor also provides excellent visualization  for the chopper’s placement. My preference is to use  4–0 polypropylene iris retractors (available from Katena  Products, Inc. [Denville, NJ], and FCI Ophthalmics, Inc.  [Marshfield Hills, MA]), because they are stiffer and easier to  manipulate than 6–0 nylon retractors. The increased girth  and sturdiness of 4–0 polypropylene iris retractors also  make them autoclavable and reusable. Finally, the IFIS pupil  is not fibrotic and typically can be maximally stretched with  retractors without tearing the sphincter muscle. Iris retractors  therefore provide the best surgical exposure of any  method for managing IFIS.

The disposable 5–0 polypropylene Malyugin Ring is my  pupillary expansion ring of choice, and most surgeons will  find it easier and faster to insert and remove than iris retractors8  (Figure 3). Because the iris drapes over the sides of the  device, it creates a round pupil with a 6- or 7-mm diameter, depending on which of the ring’s two sizes is used.   The tip of  the disposable injector goes through a 2.5-mm incision and  is used both to place and remove the ring. Compared with  bulkier plastic pupillary expansion rings, the thin profile of  the Malyugin Ring reduces the risk of accidental corneal or  incisional trauma, and it does not impede instruments’  access to the lens. There is no need for multiple paracentesis  sites, which is advantageous in the presence of a bleb or  pterygium, and the problem of iris hooks pushed against the  lid speculum with a tight palpebral fissure is avoided. Finally,  the smooth coils are very gentle on the pupillary margin,  which minimizes depigmentation and damage to the  sphincter. Because it is disposable, the Malyugin Ring is more  costly to use than reusable iris retractors.

  Some combination of   intracameral epinephrine,  Healon5, and iris expansion devices enables me to handle  the entire spectrum of IFIS severity. Knowing this, I neither  stop the patient’s systemic alpha blockers nor employ  topical atropine preoperatively. In this way, these patients  receive the same simple preoperative instructions as  everyone else undergoing routine cataract surgery

This article is reproduced with necessary updates from Cataract & Refractive Surgery Today’s April 2009 edition.

David F. Chang, MD, is a clinical professor at the   University  of California, San Francisco. He acknowledged no financial  interest in the products mentioned herein, and he stated that  his consulting fees from Abbott Medical Optics Inc. and Alcon  Laboratories, Inc., are donated to the Himalayan Cataract  Project. Dr. Chang may be reached at (650) 948-9123;  dceye@earthlink.net.

  1. Chang DF, Campbell JR.   Intraoperative floppy iris syndrome associated with tamsulosin (Flomax).  J Cataract Refract Surg. 2005;31:664-673.
  2. Chang DF, Braga-Mele R, Mamalis N, et al.   Clinical experience with intraoperative floppy-iris syndrome.  Results of the 2008 ASCRS member survey. J Cataract Refract Surg.   2008;34:1201-1209.
  3. Chang DF, Osher RH, Wang L, Koch DD.   Prospective multicenter evaluation of cataract surgery in  patients taking tamsulosin (Flomax). Ophthalmology. 2007;114(5):957-964.
  4. Chang DF, Braga-Mele R, Mamalis N, et al;   ASCRS Cataract Clinical Committee. ASCRS White  Paper: clinical review of intraoperative floppy-iris syndrome. J   Cataract Refract Surg. 2008;34(12):2153-  2162.
  5. Shugar JK. Intracameral epinephrine for   prophylaxis of IFIS [letter]. J Cataract Refract Surg.  2006;32:1074-1075.
  6. Arshinoff SA. Modified SST-USST for   tamsulosin-associated intraocular floppy iris syndrome. J  Cataract Refract Surg. 2006;32:559-561.
  7. Oetting TA, Omphroy LC. Modified technique   using flexible iris retractors in clear corneal surgery. J  Cataract Refract Surg. 2002;28:596-598.
  8. Chang DF. Use of Malyugin pupil expansion   device for intraoperative floppy iris syndrome: results  in 30 consecutive cases. J Cataract Refract Surg. 2008;34:835-841.
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