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Intraoperative Floppy Iris
Syndrome (IFIS)
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- Suresh K. Pandey MS, Vidushi
Sharma MD, FRCS
- Suvi Eye Hospital & Research
Centre
Kota, Rajasthan
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| Intraoperative Floppy Iris Syndrome or
IFIS was first described in 2005 by Chang and Campbell, as a
clinical triad observed during cataract surgery, that includes
fluttering and billowing of the iris stroma, propensity for iris
prolapse, and progressive 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 in association with the use
of tamsulosin, which is an α1-adrenergic receptor (1AR)
antagonist used in the treatment of benign prostatic
hypertrophy. Since then, many cataract surgeons from all over
the world have reviewed their own patients taking this drug and
found the same association during cataract surgery. |
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Clinical Signs of IFIS
Characteristically, the pupil dilates poorly in response to the
routine preoperative mydriatics, or starts to constrict soon
after the first incision; the iris tends to prolapse despite
well-constructed incisions, and the iris stroma can be seen to
be fluttering excessively in response to normal intraocular
fluid currents during surgery. All routine attempts to dilate
the pupil are usually ineffective and the pupil progressively
constricts further, making the surgery more
and more difficult. |
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Etiopathogenesis of IFIS
While the exact cause for this syndrome is still not clear, it
has been postulated that the alpha receptor antagonists
cause relaxation of the iris dilator muscle and cause disuse
atrophy of this muscle in the
long-term. It has been estimated that up to 2% of cataract
surgery patients may be taking tamsulosin as cataract and BPH
often coexist in the same elderly population. In a postal survey
of UK cataract surgeons, 53% surgeons had encountered the
syndrome either retrospectively or prospectively in male and
female patients on tamsulosin as well as other alpha-receptor
antagonists. Although 68% of consultants had patients
discontinue taking tamsulosin preoperatively, they reported no
consistent benefit from this step. In a similar online survey of
members of the
American Society of Cataract and Refractive Surgery, 95%
believed that tamsulosin makes cataract surgery more difficult
and 77% believed it increases the risks of surgery. Commonly
reported complications of IFIS were significant iris trauma and
posteriorcapsule rupture. |
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Systemic medications associated with IFIS
Tamsulosin is a selective alpha-1A receptor subtype antagonist,
while other non-specific alpha1 receptor antagonists, including
terazosin, doxazosin, and alfuzosin, have also been linked to
IFIS; however, their relationship to the syndrome is not as
definitive. Similarly, an anti-psychotic drug, risperidone has
also been implicated to cause IFIS. The various 1 antagonist
drugs are available in India under the following trade names:-
1. Dynapres / Urimax/ Veltam (Tamsulosin) by Dr. Reddy’s labs,
Cipla, and Intas
2. Doxacard (Doxazosin) by Cipla
3. Hytrin (Terazosin) by Abbott Labs
4. Flotral (Alfuzosin) by Ranbaxy
6. Risperidone (antipsychotic) by RPG life Sciences |
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IFIS. The various antagonist drugs
are available in India under the
following trade names:-
1. Dynapres / Urimax/ Veltam (Tamsulosin) by Dr. Reddy’s labs,
Cipla, and Intas
2. Doxacard (Doxazosin) by Cipla
3. Hytrin (Terazosin) by Abbott Labs
4. Flotral (Alfuzosin) by Ranbaxy
6. Risperidone (antipsychotic) by RPG life Sciences |
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Management of IFIS
The management of this condition begins by anticipating the
syndrome preoperatively by taking a careful history of drug use
in all cataract surgery patients. If the pupil does not dilate
preoperatively, atropine may be used, but is usually not very
effective. It is important for surgeons to pay attention to
achieve a proper wound construction, excessive hydrodissection
and excessive
injection of viscoelastic injection should be avoided. Flexible
Iris Retractors: It is better to anticipate the problem and
place iris retractors at the outset, and this is one of the best
methods
for managing this condition. Multiple sphincterotomies and
pupillary stretching is not only ineffective, it may actually
increase the propensity for iris prolapse and fluttering by
decreasing the iris tone further. This distinguishes IFIS from
other causes of small pupil, where pupillary stretching is
effective as the pupillary margins are fibrotic unlike the
floppy, atonic iris seen in IFIS. Pupil expansion rings (e.g.
PerfectPupil, Milvella Pty Ltd., Sydney, Australia) are helpful
for pupil expansion and well as for protection of prolapse iris
tissue to come in contact with phaco probe and/or dring
irrigation/aspiration. Viscoadaptive Viscoelastic- sodium
hyaluronate 2.3%, (Healon-5®): The use of viscoelastics like
Healon-5®) has also been shown to be effective in dilating the
pupil, though it needs to be replenished constantly. Slow motion
phaco is certainly a help in minimizing intraocular fluid
currents. The use of intracameral phenylephrine or epinephrine
is useful in many cases, to dilate the pupil though iris
prolapse still remains a challenge. |
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Conclusion
To conclude, IFIS is increasingly being recognized with the use
of many kinds of systemic medications used to manage BPH.
Recently,anti-psychotic drugs (e.g. risperidone) has also been
implicated to cause IFIS. While these complications were
observed by surgeons even before the discovery of this syndrome,
now we can anticipate the problem by taking a careful medical
history of using tamsulosin hydrochloride and other medications
in all elderly patients and be prepared for managing patients
identified to be at risk for having IFIS. The flexible iris
hooks are helpful for mechanical pupil enlargement and for
protection of the pupil margin in IFIS. It is also important for
surgeons to pay attention to achieve a proper wound
construction, excessive hydrodissection and excessive injection
of ophthalmic viscoelastic agents should be avoided. A
well-managed IFIS does not usually cause significant changes in
postoperative outcomes. |
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References
1. Chang DF, Campbell JR. “Intraoperative floppy iris syndrome
associated with tamsulosin.” J Cataract Refract Surg. 2005
Apr;31(4):664-73.
2. Pandey SK, Milverton EJ. The Prospective use of Perfect Pupil
Injectable for Cataract surgery in patients on Flomax. Presented
at American Academy of Ophthalmology. New Orleans, LA, USA,
November 2005.
3. Schwinn DA, Afshari NA. “alpha(1)-Adrenergic receptor
antagonists and the iris: new mechanistic insights into floppy
iris syndrome.” Surv Ophthalmol. 2006 Sep-Oct;51(5):501-12.
4. Parssinen O, Leppanen E, Keski-Rahkonen P, Mauriala T, Dugue
B, Lehtonen M. “Influence of tamsulosin on the iris and its
implications for cataract surgery.” Invest Ophthalmol Vis Sci.
2006 Sep;47(9):3766- 71.
5. Cheung CM, Awan MA, Sandramouli S. “Prevalence and clinical
findings of tamsulosin-associated intraoperative floppy-iris
syndrome.” J Cataract Refract Surg. 2006 Aug;32(8):1336-9.
6. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM,
Nichamin LD, Packard RB, Packer M; ASCRS Cataract Clinical
Committee. Clinical experience with intraoperative floppy-iris
syndrome. Results
of the 2008 ASCRS member survey. J Cataract Refract Surg.
2008;34(7):1201-9
7. Chadha V, Borooah S, Tey A, et al. Floppy Iris Behaviour
During Cataract Surgery: Associations and Variations. Br J
Ophthalmol. 2007; 91:40-42.
8. Oshika T, Ohashi Y, Inamura M, et al. Incidence of
intraoperative floppy iris syndrome in patients on either
systemic or topical alpha (1)-adrenoceptor antagonist. Am. J.
Ophthalmol 2007; 143:150-151.
9. Pandey SK, Sharma V. Prospective evaluation of viscomydriasis
using Healon-5®) and flexible iris hooks for phaco surgery in
patients on tamsulosin hydrochloride, AIOS Conference, Jaipur,
India 2009. |
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