Floppy Iris Syndrome Research Articles

A narrative review of intraoperative floppy iris syndrome: an update 2020.

Intraoperative floppy iris syndrome (IFIS) is characterized by intraoperative floppiness or billowing of the iris, progressive miosis, and iris prolapse through the surgical wounds. It was originally reported about fifteen years ago, which was later identified to be closely associated with tamsulosin, the most commonly used α1 adrenoceptor antagonist for benign prostatic hyperplasia (BPH). A variety of risk factors, including age, gender, hypertension, axial length of the eye, 5α-reductase inhibitors, other α adrenoceptor antagonist and neuromodulators, have been connected with IFIS. If IFIS occurs during phacoemulsification surgery, complications such as corneal endothelial loss, iris trauma, posterior capsule rupture (PCR), high intraocular pressure and vitreous loss are significantly increased. Therefore, preoperative evaluation of high-risk patients and appropriate intraoperative intervention is crucial to avoid severe complications. This review summarizes the pathogenesis and clinical features of classic IFIS, and provides some clinical pearls to ophthalmologists that may help identify, prevent or reduce IFIS associated complications. Additionally, from the perspective of clinical occurrence of IFIS, there are some recommendations for urologists as well. In conclusion, both ophthalmologists and urologists should be aware of this special clinical situation and communicate with each other about their own fields. A multidisciplinary interaction is of importance to simplify potentially complicated clinical issues.

Choroidal evaluation in patients under alpha-lytic therapy

PurposeTo detect any choroidal thickness (CT) change in patients after alpha-lytic drugs withdrawal that could help in the cataract surgery timing decision.MethodsTwenty-five eyes of 25 patients (mean age: 76 ± 7 years) under alpha-lytic therapy, and 25 eyes of 25 control subjects (CS) (mean age: 75 ± 7 years) without alpha-lytic therapy, both scheduled for cataract surgery in the fellow eye, were included in this observational, prospective, non-randomized study. All patients underwent EDI-OCT during the first preoperative visit and approximately 1 month (range 28–31 days) after alpha-lytic withdrawal. In the CS group, the OCT during preoperative visit and approximately 1 month after (range 28–31 days) the first examination was performed. Data normality with Kolmogorov-Smirnov test was checked and statistical evaluation with the Wilcoxon-signed rank test was performed.ResultsThe mean subfoveal CT was 224 ± 79.7 μm during therapy and 217 ± 70.4 μm after withdrawal; 1.5 mm nasally from the fovea CT was 198 ± 83.8 μm and 194 ± 82.8 μm, respectively; and 1.5 mm temporally from the fovea CT was 217 ± 55.9 μm and 205 ± 54.4 μm, respectively. A statistically significant reduction (p < 0.05) in all the 3 measured CT points was found. In the CS no significant changes were detected (p > 0.05).ConclusionNo severe floppy iris syndrome was detected at the time of surgery. In these patients, CT decrease could be an important sign for cataract surgery timing decision.

Increased pupil diameter is a protective factor against intraoperative floppy‐iris syndrome

Chang and Campbell were the first authors to describe intraoperative floppy‐iris syndrome (IFIS) in 2005 as a syndrome affecting patients undergoing routine phacoemulsification who present with a t...

Perceived Surgeon Stress During No-Sedation Topical Phacoemulsification.

PurposeTo determine the patient-related factors that contribute to surgeon stress during phacoemulsification cataract extraction (PCE) performed under unassisted topical anesthesia.MethodsThis is a prospective study of perceived surgeon stress during phacoemulsification by a single surgeon of consecutive patients undergoing PCE. At the conclusion of each procedure, the surgeon recorded the perceived stress according to the following three indices: surgeon score, qualitative score (yes or no), and total score (sum of itemized causes of stress). Patient variables included in the analysis included gender, age, diabetes mellitus, morbid obesity, intake of oral alpha blockers, floppy iris, laterality, pseudo-exfoliation, intraocular lens power, and initial visual acuity.ResultsDuring the 10-year study, 1097 eyes underwent surgery. The following patient variables were seen frequently: floppy iris syndrome (92), pseudo-exfoliation (72), and morbid obesity (36). Surgeon identified stress was reported after 250 procedures. On multivariable analysis, the following patient characteristics were associated with surgeon stress: age >80 years; morbid obesity; floppy iris syndrome; severe nuclear sclerosis; and poor baseline distance corrected visual acuity.ConclusionSeveral ocular and systemic patient-related characteristics contribute to surgeon stress during PCE.

Modified hydrodissection to prevent intraoperative iris prolapse.

A modified hydrodissection technique to prevent intraoperative iris prolapse is presented. The phacoemulsification tip is inserted into the main ocular incision while hydrodissection is performed through a side-port incision. Placement of the phacoemulsification tip in this location prevents iris prolapse. This technique can be used routinely and might be especially applicable in cases with a high risk for iris prolapse, such as in intraoperative floppy-iris syndrome.

Managing intraoperative floppy iris syndrome with I-ring pupil dilator

Managing intraoperative floppy iris syndrome with I-ring pupil dilator

Bilateral Intraoperative Floppy Iris Syndrome Associated with Silodosin Intake.

Intraoperative floppy iris syndrome (IFIS) is described by three characteristics: floppy iris that billows in reaction to intraocular fluid currents during phacoemulsification surgery, flaccid iris stroma that tends to prolapse through well-constructed surgical incisions, and progressive pupillary miosis despite preoperative pharmacologic dilatation. A 63-year-old man presented with decreased vision in both his eyes. Ophthalmic examination revealed bilateral nuclear cataract. He was prescribed silodosin for the management of benign prostatic hyperplasia a month ago. Consecutive cataract surgery was planned at a 2-week time interval. All features of IFIS were encountered in both eyes of the patient during phacoemulsification surgery. IFIS was successfully managed by the aid of an iris retractor, and a 20/20 final visual acuity was achieved postoperatively in both eyes of the patient. To the best of our knowledge, this is the first study about bilateral IFIS associated with silodosin intake. Ophthalmologists and urologists prescribing silodosin should be aware of this possible association.

Modelling floppy iris syndrome and the impact of pupil size and ring devices on iris displacement

IntroductionThe aim of this paper was to further develop a previously described finite element model which equates clinical iris billowing movements with mechanical buckling behaviour, simulating floppy iris syndrome. We wished to evaluate the impact of pupil dilation and mechanical devices on normal iris and floppy iris models.MethodsTheoretical mathematical modelling and computer simulations were used to assess billowing/buckling patterns of the iris under loading pressures for the undilated and dilated normal iris, the undilated and dilated floppy iris, and additionally with a mechanical ring device.ResultsFor the normal iris, billowing/buckling occurred at a critical pressure of 19.92 mmHg for 5 mm pupil size, which increased to 28.00 mmHg (40.56%) with a 7 mm pupil. The Malyugin ring device significantly increased critical initiating buckling pressures in the normal iris scenario, to 34.58 mmHg (73.59%) for 7 mm ring with boundary conditions I (BC I) and 34.51 mmHg (73.24%) with BC II. For the most floppy iris modelling (40% degradation), initiating buckling value was 18.04 mmHg (−9.44%), which increased to 28.39 mmHg (42.52%) with the 7 mm ring. These results were much greater than for normal undilated iris without restrictive mechanical expansion (19.92 mmHg).ConclusionThis simulation demonstrates that pupil expansion devices inhibit iris billowing even in the setting of floppy iris syndrome. Our work also provides a model to further investigate the impact of pupil size or pharmacological interventions on anterior segment conditions affected by iris position.

Intraoperative Floppy Iris Syndrome: Updated Perspectives.

Almost fifteen years since its initial description, intraoperative floppy iris syndrome (IFIS) during phacoemulsification surgery remains a challenge for cataract surgeons in all its key aspects that include the stratification of the preoperative risk, preoperative prophylaxis treatment, surgery design and intraoperative management. Since its original association with tamsulosin intake, IFIS has been positively correlated with a plethora of risk factors which include: gender, age, hypertension, other a1-adrenergic receptor antagonists, finasteride, angiotensin II receptor inhibitors, benzodiazepines, antipsychotics, hypertension drugs and decreased dilated pupil diameter. The assessment and stratification of the preoperative risk is pivotal in screening patients prone to develop IFIS. For these patients, it is essential that preoperative prophylaxis, employment of necessary measures and surgical technique modifications are considered. A multidisciplinary approach of IFIS is a mandate, thus ophthalmologists, urologists and sometimes other specialties should cooperate to “educate” each other about the risks of their respective fields. They both must be aware of the joint statement on IFIS by the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery which suggests either the initiation of tamsulosin after phacoemulsification or the use of a non-selective a1-ARA for benign prostatic hyperplasia treatment. In conclusion, awareness of the risk factors associated with IFIS and their detailed preoperative documentation is crucial in addressing IFIS. The lack of such an awareness can turn a routine, uneventful surgery into one with significant visual morbidity.

Dexmedetomidine Associated with Intraoperative Floppy Iris Syndrome in Ophthalmic Surgery

Dexmedetomidine Associated with Intraoperative Floppy Iris Syndrome in Ophthalmic Surgery

Ophthalmology Residents' Experience with Complex Cataract Surgery at a VA Hospital over 10 Years

Abstract Objective The purpose of this study was to determine the proportion of complex cataract surgery performed by third-year ophthalmology residents at an academic Veterans Administration Medical Center. Methods A chart review was conducted of all resident cataract surgeries performed at the James J. Peters Veterans Administration Medical Center in The Bronx, NY between July 1, 2007, and June 30, 2017. Correct categorization was confirmed by review of operative report and reason for complex categorization was recorded, as well as the use and type of nonstandard device or technique. Results A total of 2,429 routine and 114 complex cataract surgeries were performed by 40 different residents over the 10-year period. In total, 4.5% of all cataract surgeries were categorized as complex. The most common reasons for complex categorization included intraoperative floppy iris syndrome (35.8%), miosis (38.4%), zonular instability (9.6%), mature cataract (7%), posterior synechiae (7.8%), and posterior capsular plaque (1.8%). Nonstandard techniques/devices included iris hooks (65.3%), pupil expansion device (8.5%), extracapsular cataract extraction (6.8%), synechiolysis (7.6%), mechanical iris dilation (0.8%), capsular tension ring (9.3%), and primary posterior continuous curvilinear capsulorhexis (1.7%). Conclusion A review of third-year resident cataract surgery experience at our institution's VA hospital where a significant amount of their surgical volume, approximately 50%, is obtained revealed that complex cataracts constituted a minimal portion of the cases. Education in cataract surgery should be competency based, extend beyond achieving minimums, and focus on variety and complexity of surgical experience. Formal tracking of routine versus complex cases should be considered to optimize training experience and assure patient safety.

Urology Residency Directors' Awareness of Association between α-Adrenergic Antagonists and Floppy Iris Syndrome and Practice Patterns Regarding Prophylactic α-Adrenergic Antagonists

Purpose The use of prophylactic α-adrenergic receptor antagonists prior to surgery is associated with reduced postoperative urinary retention. However, α-adrenergic receptor antagonists have been associated with intraoperative floppy iris syndrome (IFIS). Studies have shown that IFIS is correlated with higher rates of cataract surgery complications. The purpose of this study is to investigate United States urology residency program directors' (1) awareness of the association between α-adrenergic receptor antagonists and IFIS and (2) practice patterns regarding the use of prophylactic α-adrenergic receptor antagonists prior to surgery. Materials and Methods An anonymous, online survey was sent to the program director of each of the 138 urology residency programs accredited by the Accreditation Council for Graduate Medical Education. The survey assessed program directors' knowledge regarding the association between α-adrenergic receptor antagonists and IFIS, and practice patterns regarding the use of prophylactic α-adrenergic receptor antagonists prior to surgery. Results Sixty-nine of the 138 (50%) residency directors responded. Forty percent of respondents believe that tamsulosin (Flomax) does not increase the risk of IFIS. Fifty-two percent of respondents prescribe or consider prescribing prophylactic α-adrenergic blockers prior to surgery, with tamsulosin being the most preferred α-adrenergic blocking agent. Of the prescribing urologists, only 58% counsel most of their patients regarding the association between the prescribed drug and IFIS, 28% never ask patients whether they have had cataract surgery, and 56% would change the drug or dosage used if they learned that a patient had not yet had cataract surgery. Conclusion The results of this study demonstrate the potential to decrease the risk of IFIS through education of urologists regarding the association of α-adrenergic antagonists with IFIS.

Evolution in the Risk of Cataract Surgical Complications among Patients Exposed to Tamsulosin: A Population-Based Study

Tamsulosin is associated with intraoperative floppy iris syndrome (IFIS), an important risk factor for complications during cataract surgery. Significant efforts have been made to increase awareness of the risks associated with tamsulosin, and educational initiatives have fostered the uptake of technical adjustments to decrease adverse event rates among tamsulosin-exposed patients. However, the effectiveness of these efforts at the population level has not been studied. Population-based study to evaluate cataract surgical adverse event rates over time among patients exposed to tamsulosin and those not exposed to this drug. All male patients 66 years of age and older undergoing cataract surgery in Ontario, Canada, between January 1, 2003, and December 31, 2013, were included in the study. Linked healthcare databases were used to study the evolution in the risk of cataract surgical adverse events over time among tamsulosin-exposed and non-tamsulosin-exposed patients adjusting for patient-, surgeon-, and institution-level covariates. The study timeframe incorporated periods before and after the first reports of tamsulosin-associated IFIS. Four important cataract surgical adverse events were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Among patients exposed to tamsulosin, the risk of surgical adverse events decreased over time (odds ratio, 0.95 per year; 95% confidence interval, 0.91-0.99 per year). This trend was observed across patient age strata. Among patients not recently exposed to tamsulosin, the risk of surgical adverse events also decreased over time (odds ratio, 0.96 per year; 95% confidence interval, 0.95-0.98 per year). The risk of cataract surgical complications among both tamsulosin-exposed and non-tamsulosin-exposed patients declined between 2003 and 2013. Tamsulosin remains an important risk factor for cataract surgical adverse events, and ongoing efforts will be needed to develop and disseminate surgical approaches that mitigate the risks posed by tamsulosin.

The Effect of Preoperative Homatropine for Intraoperative Floppy Iris Syndrome in Patients Taken Alpha Blockers

The Effect of Preoperative Homatropine for Intraoperative Floppy Iris Syndrome in Patients Taken Alpha Blockers

Modified Corneal Incisions for Cataract Surgery in Patients Treated with Tamsulosin: A Prospective Study

ABSTRACTPurpose: To evaluate modified anterior elongated corneal incisions as a simple technique to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS), in patients taking tamsulosin (a selective α1a-adrenergic receptor antagonist).Methods: This prospective case series was conducted at Meir Medical Center, a tertiary care facility in Israel. Included were 45 eyes of 39 male patients taking tamsulosin, and thus prone to IFIS. Patients underwent phacoemulsification cataract surgery with anterior elongated corneal incisions. The primary outcomes were the incidence and severity of IFIS, the complication rate and the need for additional IFIS management techniques. The secondary outcome was to quantify the surgically induced astigmatism, using Alpin’s vector analysis. The tamsulosin treatment period and pupil diameter during five stages of the surgery were also noted.Results: The overall rate of IFIS was 33.33% (n = 15). The IFIS severity was rated as mild in 22.22% and moderate in 11.11% of the study eyes. No IFIS was noted in 66.67% of the eyes. There were no cases of severe IFIS, and no need for other IFIS management strategies. The complications rate was 2.22% (n = 1). Patients who developed IFIS had a significantly smaller pupil at the beginning of surgery (p < 0.05). There was no significant difference in tamsulosin treatment period between patients with and without IFIS (p = 0.19). The centroid – the mean SIA vector was 0.51 D @ 18° ±1.5 D (SD).Conclusions: In tamsulosin treated patients, using modified corneal incisions may be feasible in order to reduce the incidence and severity of IFIS during cataract surgery. Future randomized studies are warranted.

The Pharmacological Mydriatic Pupil-to-Limbal Diameter Ratio as an Intuitive Predictor for the Risk of Intraoperative Floppy Iris Syndrome.

Purpose To predict development of intraoperative floppy iris syndrome (IFIS) using the preoperative pharmacologically dilated pupil-to-limbal diameter (PL) ratio. Methods The subjects were male patients treated by phacoemulsification who were or were not taking α1-adrenoceptor antagonists (ARAs). The PL ratio was calculated from the horizontal dilated pupil diameter and the horizontal corneal white-to-white distance measured by two observers in surgical videos. IFIS severity was graded using the criteria of Chang et al. We predicted the intuitive PL ratio to describe how precisely the experimenter can estimate the PL ratio without any tools. Results There were 36 eyes in the α1-ARA group and 48 eyes in the control group. The pupil diameter and PL ratio were both significantly smaller in the α1-ARA group compared to the control group (p < 0.001). All of pupil diameter, PL ratio, and intuitive PL ratio were negatively correlated with IFIS severity. The cutoff value for prediction of IFIS from the ROC curve was 7.20 mm for the pupil diameter, 58.7% for the PL ratio, and 62.5% for the intuitive PL ratio. The AUC for the ROC curve using the PL ratio (0.913) and intuitive PL ratio (0.892) did not perform substantially worse than that for the ROC curve based on the pupil diameter (0.875). Conclusions The PL ratio is a simple and useful parameter for compensated prediction of IFIS development. Patients in whom this ratio is <60% are particularly likely to develop IFIS, and measures against onset of IFIS should be considered. This study is registered with UMIN000033012.

The role of sex in intraoperative floppy-iris syndrome

To compare the incidence of intraoperative floppy-iris syndrome (IFIS) between male and female patients undergoing phacoemulsification cataract surgery, evaluate risk factors for its appearance in each sex, and assess any differences in the final visual outcomes. 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Greece. Comparative retrospective case-control study. Cataract patients with recorded IFIS of any severity occurring over 4years in a tertiary care ophthalmic center during phacoemulsification surgery were identified and enrolled in a multivariate analysis. The study comprised 3811 eyes of 3213 patients. Of the 1678 female patients (1937 eyes) undergoing cataract surgery, IFIS was observed in 25 eyes (1.29%), whereas the incidence of IFIS in male eyes during the same period was statistically significantly higher (97 [5.17%] of 1874 eyes) (P<.0001). No statistically significant difference in age was found between male patients (72.92years±6.5 [SD]) and female patients (72.04±7.1years) (P=.56). An intake of α1-receptor blockers was identified in 70 (72.2%) of 97 male IFIS cases and in none of the 25 female IFIS cases (P<.0001). The posterior capsule rupture rate was significantly higher in 7 (28%) of the 25 female IFIS cases compared with 9 (9.28%) of the 97 male IFIS cases (P=.02). The posterior capsule rupture incidence and final corrected distance visual acuity (with spectacles) were shown to correlate with the IFIS severity grade only in female patients (P<.001 and P=.02, respectively). Although the incidence of IFIS is rarer in female patients, it might significantly affect an increase in the intraoperative events rate and affect the final visual outcome correlating with the severity grade of its appearance. Predisposing risk factors differ between the sexes and surgeons should always be aware of the potentially catastrophic consequences of unforeseen IFIS.

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study

To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons. Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. Retrospective chart review. All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed. In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group1month after surgery (0.051±0.10 [SD] versus 0.132±0.30, P=.03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8±26.5minutes and 30.9±12.6minutes for cases performed by resident surgeons and attending surgeons, respectively (P.0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P=.008). The overall rate of adverse events was no different between residents and attending surgeons (P=0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P=.001). Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.

Complications of cataract surgery in Wistar rats undergoing treatment with tamsulosin.

The aim of the study was to identify if there is a connection between the time of administration of alpha-blocker medication and cataract surgery complications. Furthermore, it was explored whether discontinuation of tamsulosin before cataract surgery influences the manifestations of intraoperative floppy iris syndrome in rats. An experimental study was conducted on 20 male Wistar rats aged 1.5–2 years (body mean weight 357 g), which were divided into four equal groups: Group 1, under tamsulosin hydrochloride 0.4 mg/day for 2 months; group 2, without any treatment in the first month, followed by tamsulosin; group 3, under tamsulosin for 1 month, followed by 1 month without any treatment; and group 4, control. The pupillary diameter was assessed before instillation of 0.5% tropicamide (mydriatic and cycloplegic agent), after 1 or 2 h from instillation and postoperatively. Furthermore, pupil constriction during surgery, the presence of floppy iris and prolapse of the iris following the main incision and during serum injection were also assessed. Other analyzed features included iris rupture, posterior capsule tear, vitreous loss, lens fragments in the vitreous, suprachoroidal bleeding and corneal haze. The iris dilator muscle thickness and the posterior epithelium was measured using light microscopy. In the control group, the largest pupillary diameters were indicated and in group 1, the smallest pupillary diameters were revealed. Statistically significant differences were indicated between group 1 and 2 and group 3 and 4. Floppy iris, iris prolapse in the main incision and during serum injection appeared at maximum frequency for group 1 with continuous treatment and low frequency for the control group. Lens fragments in the vitreous were present in the groups 1–3. Notably, intraoperative miosis had statistical relevance in group 1 and group 2. To conclude, the present findings suggested there is a clear connection between the time of administration of the alpha-blocker medication and most cataract complications. The results indicated that discontinuation of tamsulosin for one month largely reduces the manifestations of intraoperative floppy iris syndrome in rats, which may suggest to change preoperative treatment for benign prostatic hypertrophy with another class of drugs that do not interact with the iris receptors.

Intraoperative complication rates in cataract surgery performed by ophthalmology resident trainees compared to staff surgeons in a Canadian academic center

To compare the intraoperative complication rates in cataract surgery performed by resident trainees and staff ophthalmologists. Kensington Eye Institute, University of Toronto, Toronto, Canada. Prospective case series. This study included 8738 consecutive cases of primary phacoemulsification cataract surgery performed by staff surgeons and resident trainees from January to December 2016. There were no exclusion criteria. Data collected included the level of resident training, case complexity, degree of resident involvement, and intraoperative complications. Primary outcome measures included intraoperative complication rates and level of complexity of cataract surgeries performed by resident trainees and staff surgeons. Resident trainees were involved in 44% of surgeries. Of those, 82% were completed in their entirety by a resident and 18% were performed by both the staff surgeon and resident. Staff surgeons performed 56% of all surgeries without resident involvement. Sixty-seven percent of surgeries were simple and 33% were complex, with small pupil or intraoperative floppy-iris syndrome being the most common reason for complex cases. For simple cases, there was no difference in the overall complication rates (1.7% and 2.0%; P=.52), posterior capsule rupture rates (0.9% and 0.8%; P=.76), or vitreous loss rates (0.4% and 0.2%; P=.08) between staff and residents, respectively. There were no differences in complication rates between the two groups.