Intraoperative floppy-iris syndrome: Role of the bimanual approach

Abstract

Several approaches to manage iris behavior in IFIS were mentioned in the recent review of intraoperative floppy-iris syndrome (IFIS).1 We agree that interventions such as high-viscosity ophthalmic viscosurgical devices (OVD), intracameral phenylephrine, and iris retractors can assist the surgeon in improving the surgical outcome in patients using systemic α1-antagonists.2 These preventive measures can often control the unpredictable iris movement without resorting to mechanical devices. However, the situation can quickly deteriorate during irrigation and aspiration (I/A), resulting in subsequent iris prolapse and damage. This unpredictability can occur despite a well-dilated pupil preoperatively, a sign that can falsely reassure the surgeon. We wish to further highlight the issue of fluidics during removal of the cortical lens material in IFIS. We believe the use of coaxial I/A contributes to iris instability and subsequent prolapse because the source of irrigation is posterior to the iris. The flow rate used appears to correlate with the degree of iris billowing. In our experience, intraoperative conversion from coaxial to bimanual I/A can reduce the intraocular instability. This benefit is not restricted to microincisional phacoemulsification alone, as mentioned in the review. The separation of irrigation and aspiration in the bimanual approach seems to reduce the degree of iris movement. Bimanual I/A enables safe removal of the cortical lens material and appears to be superior to a coaxial approach in this setting as it does not create a vulnerable 1-way valve at the main incision.3 We have also found that keeping the irrigation cannula above the iris diaphragm, with the tip directed to the iris posterior to the main wound, helps prevent iris prolapse during OVD removal. It is our assertion that a planned bimanual approach in patients predicted to have IFIS may improve intraoperative conditions, reduce potential iris damage, and improve the surgical outcome.