para>Patient use of tamsulosin, among other α-blockers, is associated with a significant increase in the risk for the development of IFIS (1).
Primary care physicians, mindful of a 2007 study that showed that 96.8% of primary care physicians surveyed in the United Kingdom were unaware of IFIS, should take the risk of IFIS into account when prescribing α-blockers, inquire about cataract history, advise patients to inform ophthalmologists of the use of α-blockers (5).
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GENERAL PREVENTION
- Offer patients a complete ophthalmologic assessment prior to starting an α-blocker.
- Give consideration to identification of cataracts and to surgical removal prior to starting α-blocker.
- Suspend use of α-blockers prior to surgery.
- Such discontinuation is not always effective, as any prior use of tamsulosin can still predispose those patients to IFIS (4).
- Discontinuing α-blockers can also cause urinary retention, which may be exacerbated during surgery (4).
- Use of preoperative atropine is controversial, as evidence is lacking that it reduces the risk of iris prolapse (1).
COMMONLY ASSOCIATED CONDITIONS
None �
DIAGNOSIS
HISTORY
- Inquire about use of tamsulosin, other α-blockers, especially in male patients with known BPH.
- Review patient use of other medications linked to IFIS.
- Attention should be paid to significant comorbid conditions, including hypertension.
PHYSICAL EXAM
- Thorough preoperative ophthalmologic examination
- Determine configuration of iris, as convex iris is associated with greater risk of IFIS (6)[C].
- Examine the depth of the anterior chamber, as shallow chamber is noted to incur a greater risk of IFIS (6)[C].
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
A handheld digital pupillometer can be used by an ophthalmologist preoperatively to measure pupil size and constriction velocity (3)[B]. �
- Use of α-blockers, notably tamsulosin and alfuzosin, is associated with a decrease in pupil diameter and reduced constriction velocity, both risk factors for the development of IFIS (3)[B].
- Patients with dilated pupil sizes of 7 mm or less are at increased risk of developing IFIS, independent of the use of α-blockers (7).
TREATMENT
GENERAL MEASURES
Management begins with prevention (1)[B]. �
MEDICATION
First Line
- Injection of 0.6 mL intracameral 1.5% phenylephrine before or during surgery (1)[B]
- Preoperative prophylactic use can prevent IFIS, whereas intraoperative use can reverse IFIS, restore iris rigidity, and cause pupil to return to its preoperative size.
- Sub-Tenon injection of 2.5 mL of 2% lidocaine is associated with 8.8% incidence of IFIS, compared to 48.6% among patients who received 1% intracameral injections of lidocaine (8)[B].
- Sub-Tenon injection of 2% lidocaine provides prolonged effect, lasting more than an hour, as opposed to the 10- to 15-minute effect of intracameral injections of lidocaine.
- Preoperative use of atropine is not proven to prevent iris prolapse (1)[B].
ADDITIONAL THERAPIES
- Intraoperative application of mechanical devices to maintain mydriasis (1)[B]
- Iris hooks or retractors
- Malyugin ring
- Ophthalmic viscosurgical devices (OVDs) (6)[B]
- Allow for viscodilation of a small pupil.
- Act as barriers against a prolapsing iris
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Recommendations for follow-up based on operative outcome and postoperative complications �
- In general, 3 months postoperative observation is recommended.
PATIENT EDUCATION
- Patients with any degree of cataract formation who may be surgical candidates in the future and who are considering use of α-antagonists should be educated about the risk of IFIS.
- Physicians prescribing α-antagonists should be aware of the risk of IFIS and consider that risk when referring patients to ophthalmologist for cataract procedures.
PROGNOSIS
Dependent on surgical outcome, in the wake of IFIS, and on any postoperative complications �
COMPLICATIONS
40% higher incidence of complications in patients who develop IFIS (1) �
- Iris atrophy
- Posterior capsule rupture
- Zonular deinsertion
- Vitreorragia
- Iridodialysis
- Postsurgery hypertensive peak
- Hyphema
- Diplopia and photophobia due to iris lesion
REFERENCES
11 Gonz �lez Mart �n-Moro �J, Mu �oz Negrete �F, Lozano Escobar �I, et al. Intraoperative floppy-iris syndrome. Arch Soc Esp Oftalmol. 2013;88(2):64-76.22 Chatziralli �IP, Sergentanis �TN. Risk factors for intraoperative floppy iris syndrome: a meta-analysis. Ophthalmology. 2011;118(4):730-735.33 Theodossiadis �PG, Achtsidis �V, Theodoropoulou �S, et al. The effect of alpha antagonists on pupil dynamics: implications for the diagnosis of intraoperative floppy iris syndrome. Am J Ophthalmol. 2012;153(4):620-626.44 Flach �AJ. Intraoperative floppy iris syndrome: pathophysiology, prevention, and treatment. Trans Am Ophthalmol Soc. 2009;107:234-249.55 Doss �EL, Potter �MB, Chang �DF. Awareness of intraoperative floppy-iris syndrome among primary care physicians. J Cataract Refract Surg. 2014;40(4):679-680.66 Tint �NL, Dhillon �AS, Alexander �P. Management of intraoperative iris prolapse: stepwise practical approach. J Cataract Refract Surg. 2012;38(10):1845-1852.77 Casuccio �A, Cillino �G, Pavone �C, et al. Pharmacologic pupil dilation as a predictive test for the risk for intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2011;37(8):1447-1454.88 Klysik �A, Korzycka �D. Sub-Tenon injection of 2% lidocaine prevents intra-operative floppy iris syndrome (IFIS) in male patients taking oral α-adrenergic antagonists. Acta Ophthalmol. 2014;92(6):535-540.
CODES
ICD10
H21.81 Floppy iris syndrome �
ICD9
364.81 Floppy iris syndrome �
SNOMED
- intraoperative floppy iris syndrome (disorder)
- Tamsulosin-associated floppy iris syndrome
CLINICAL PEARLS
- IFIS is a potential complication of cataract removal surgery and is distinguished by the intraoperative triad of a flaccid iris seen to billow during surgery, hence, the floppy iris, which can then prolapse through surgical incisions.
- Greatest risk for the development of IFIS is conferred by current or any former use of α-antagonists, especially tamsulosin.
- Consider referral to ophthalmology, preemptive surgical removal of cataracts, prior to starting an α-blocker.
- Preoperative ophthalmologic examination should include an assessment of anterior chamber depth and configuration of iris, examination by pupillometer, if available, to evaluate pupil size and constriction velocity.
- Consider preoperative prophylactic use of intracameral injection of phenylephrine if patient is at known risk of IFIS.
- Should IFIS develop, consider intracameral injection of phenylephrine or sub-Tenon injection of lidocaine; be prepared, intraoperatively, for the use of mechanical devices, including iris hooks or retractors, Malyugin ring, or ophthalmic viscosurgical devices.
- Patients who experience IFIS have a 40% higher incidence of postoperative complications.
- Dilated pupil sizes ≤7 mm are associated with an increased risk of IFIS, regardless of any prior use of α-blockers.
- Primary care physicians should consider a patient's cataract history before prescribing α-blockers, should ensure that a patient's ophthalmologist knows of any α-blocker use.