Intraoperative Floppy Iris Syndrome in patients on alpha 1 blocker tamsulosin: incidence and predictability

Background: Intraoperative Floppy Iris Syndrome (IFIS) was first described by Chang and Campbell in year 2005 in male patients undergoing phacoemulsification surgery who were on Tamsulosin, an alpha 1 blocker drug for their urinary symptoms for enlarged prostate. This condition was characterized by excessive floppiness of iris, prolapse of iris tissue through phaco and sideport incisions and progressive intraoperative miosis, resulting in increased surgical time and various major surgical complications compromising visual outcome.Methods: This study of 78 patients was undertaken to know the incidence and severity of IFIS as well as to predict its occurrence by observing maximum pupil dilation achieved preoperatively.Results: It was observed that majority of patients on tamsulosin dilated poorly and severe IFIS occurred in those with pupil dilation of 5 mm or less after putting mydriatic eye drops preoperatively.Conclusions: It was concluded that if IFIS was predicted and necessary precautions taken, postoperative complications can be reduced significantly with improved visual outcome.

Clinical study on intraoperative floppy iris syndrome / 眼科新进展

In recent years,there are many studies have reported that a small pupil syndrome appeared during routine phacoemulsification in patients with current or previous use of alpha-1 adrenergic receptor antagonists,with these clinical manifestations:an iris that appears floppy as it billows during normal irrigation and aspiration in the anterior chamber,a tendency for the iris to prolapse and progressive intraoperative miosis during surgery,which called intraoperative floppy iris syndrome This article mainly reviews the mobidity,pathogenesis,clinical features,complications,prophylaxis and treatment of the intraoperative floppy iris syndrome.

A study of risk factors and predictive factors in intraoperative floppy iris syndrome during phacoemulsification / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To determine the incidence of intraoperative floppy iris syndrome (IFIS) in patients undergoing phacoemulsification in a Chinese hospital,and to assess new risk factors and predictive factors for IFIS.METHODS:A prospective,observational case series.In the consecutive cataract surgeries performed in one year,the medicine administration,pupil size (PS)before and after mydriasis,and signs of IFIS were recorded.RESULTS:Totally 807 patients (1068 eyes) underwent cataract surgeries.Among the 1068 eyes,signs of IFIS were noted in 34 eyes.Strong positive correlations were showed between finasteride (6.4％,OR =5.885),tamsulosin (25％,OR=21.578),reserpine (16.7％,OR=12.947),clozapine (66.7％,OR=139.467),post-panretinal photocoagulation (14.3％,OR =10.789) and IFIS.Pupil size was inversely related to IFIS incidence (P＜0.001).A dilated pupil smaller than 7.25mm could predict iFiS (P＜0.001).CONCLUSION:The incidence rate of IFIS was 3.18％.Reserpine,clozapine and post-panretinal photocoagulation emerged as new risk factors for IFIS.A small dilated pupil may imply IFIS occurrence.

Frecuencia y factores pronósticos del síndrome de iris laxo intraoperatorio / Frequency and prognostic factors of the intraoperative floppy iris syndrome

Objetivo: evaluar la frecuencia, los factores pronósticos y el impacto del síndrome de iris laxo intraoperatorio en operaciones de catarata. Métodos: se realizó un estudio de cohorte prospectivo y longitudinal, donde se evaluaron 139 operaciones de catarata realizadas por un solo cirujano, de los cuales 49 ojos (35,3 por ciento) presentaron síndrome de iris laxo intraoperatorio. Se realizó un análisis univariado y multivariado con variables demográficas, antecedentes patológicos personales, uso de medicamentos, características anatómicas del iris, parámetros biométricos y complicaciones intra y posoperatorias. Resultados: en el análisis univariado las variables significativas pronósticas para la aparición de síndrome de iris laxo intraoperatorio fueron: el consumo de psicofármacos (p= 0,001), la cámara anterior estrecha (p= 0,001) y la dilatación pupilar preoperatoria regular o mala (p= 0,001). En el análisis multivariado la cámara estrecha fue, de todas las variables independientes, la que mayor influencia tuvo en la aparición de síndrome de iris laxo intraoperatoriocon una alta significación (p= 0,001). El síndrome de iris laxo intraoperatorio aumentó el riesgo de complicaciones intra y posoperatorias. Conclusiones: con una correcta anamnesis y un examen oftalmológico podemos predecir la ocurrencia de síndrome de iris laxo intraoperatorio durante la cirugía de catarata. El consumo de psicofármacos, la cámara anterior estrecha y la dilatación pupilar preoperatoria regular o mala se pueden considerar factores pronósticos de síndrome de iris laxo intraoperatoriodesde el preoperatorio(AU)

Objective: to evaluate the frequency, the prognostic factors and the impact of the intraoperative floppy iris syndrome in cataract surgery. Method: a prospective and longitudinal cohort study of 139 cataract surgeries performed by the same surgeon, of which 49 eyes (35,3 pércent) presented with intraoperative floppy iris syndrome. An univariate/multivariate analysis was made taking on account demographic, personal history of pathologies, use of medications, anatomical characteristics of the iris, biometric parameters and complications during and after the surgery. Results: in the univariate analysis, the significant prognostic variables for the intraoperative floppy iris syndrome were consumption of antipsychotics (p= 0,001), narrow anterior chamber (p= 0,001) and regular or bad dilated pupil (p= 0,001) before surgery. In the multivariate analysis, the narrow anterior chamber was, among all the independent variables, the most influential for the onset of the intraoperative floppy iris syndrome, with a highly significant association (p= 0,001). The intraoperative floppy iris syndrome increased the intra and postoperative risk for complications. Conclusions: correct interrogation and an eye exam can predict the occurrence of intraoperative floppy iris syndrome during the cataract surgery. The use of antipsychotics, the narrow anterior chamber and regular or bad pupil dilation before the surgery can be considered as prognostic factors for the intraoperative floppy iris syndrome(AU)

Research progress of intraoperative floppy iris syndrome during phacoemulsification / 国际眼科杂志(Guoji Yanke Zazhi)

? Intraoperative floppy iris syndrome is a particular symptom in phacoemulsification, and it is often occurred in patients with the history of using alpha-1 adrenergic antagonist before cataract surgery. Although the pupil be fully mydriatic before the operation, the progressive constricting of the pupil, the relaxing of iris even the iridoptosis and the unstable anterior chamber still can be found during the phacoemulsification. If treated inappropriately, severe complications and terrible outcomes may happen, which would influenced the surgery effectives. This paper reviewed the epidemiological characteristics, pathogenesis, risk factors, clinical manifestations, complications, and coping strategies of the intraoperative floppy iris syndrome.

Incidence and Risk Factors of Intraoperative Floppy Iris Syndrome During Cataract Surgery

PURPOSE: To determine the incidence and risk factors of intraoperative floppy iris syndrome (IFIS) in patients undergoing cataract surgery. METHODS: The present study included 981 eyes of 655 patients who underwent cataract surgery and development and grade of IFIS were recorded. Correlation analysis was performed to determine the relationship between the IFIS and risk factors such as alpha1-adrenergic antagonist (tamsulosin, terazosin, alfuzosin), benzodiazepine, 5-alpha-reductase inhibitor, age, gender, hypertension, diabetes and glaucoma. RESULTS: IFIS developed in 178 eyes (18.1%) out of 981 eyes. There was a correlation between the development of the IFIS and alpha1-adrenergic antagonist and benzodiazepine and male gender; however, there was no correlation with 5-alpha-reductase inhibitor, age, gender, hypertension, diabetes and glaucoma. IFIS grade tended to be higher as the cumulative dosage of the alpha1-adrenergic antagonist increased. Odds ratio of the patients using tamsulosin was the highest among the other risk factors, which was 3.8 times higher than the patients using terazosin, 9.0 times higher than the patients using alfuzosin and 11.1 times higher than the patients using benzodiazepine. Among patients who underwent cataract surgery on both eyes and who were confirmed with IFIS in 1 or both eyes, no significant grade differences between the 2 eyes were noted. CONCLUSIONS: Alpha 1-adrenergic antagonist and benzodiazepine were risk factors for the development of the IFIS, and as the cumulative dosage of the alpha1-adrenergic antagonist increased, the probability of developing a higher grade of IFIS increased. Therefore, predicting and preparing for potential IFIS in patients who have the above-mentioned risk factors are necessary before planning cataract surgery. Additionally, the IFIS aspect of the first eye could be utilized as a predictive value for developing IFIS profile of the fellow eye.

Floppy iris syndrome with oral imipramine: A case series.

Intraoperative floppy iris syndrome (IFIS) has commonly been seen with long-term use of α1-adrenoceptor blocking agents. We observed IFIS in three patients during phacoemulsification due to oral imipramine therapy. The three patients took imipramine for 25 years, 10 months and 1 year, respectively. However, only the first patient was on oral therapy at the time of surgery, while the other two patients had stopped 4 months and 2 months prior to undergoing phacoemulsification. The first and third patients developed complete IFIS features, while the second had only partial IFIS characteristics. Phacoemulsification could be completed in all three patients without any complication. None of these patients had history of taking any of the α1-adrenoceptor blocking agents. This is the first anecdotal report of IFIS with the oral use of imipramine and hence further evidences are required to ascertain the association of oral imipramine therapy and IFIS. However, ophthalmologists undertaking phacoemulsification on patients on imipramine therapy should be alert for the occurrence of IFIS.

The Effect of alpha1-Adrenergic Blocker on Phacoemulsification

PURPOSE: To evaluate the influence of alpha1-adrenergic blocker on phacoemulsification and the preventive effect of adrenergic blocker (AB) cessation before cataract surgery. METHODS: A prospective study was performed involving 92 eyes of 60 patients undergoing cataract surgery. Cases were divided into three groups: the use of alpha1AB with discontinuance before surgery (32 eyes), the use of alpha1AB with no discontinuance before surgery before surgery (31 eyes), and eyes not treated with alpha1AB (29 eyes). Clinical measurements and intraoperative parameters were compared among the three groups. RESULTS: Preoperative maximum pupil diameters of patients treated with alpha1AB were smaller than those of patients not administered alpha1AB (p = 0.027 and p = 0.018, respectively). The incidence of IFIS in the patients using of alpha1AB with discontinuance before surgery was 6.25%, and that in the patients using of alpha1AB with no discontinuance before surgery was 6.45%. There was no IFIS outbreak in the patients not using of alpha1AB. We noted no significant differences in absolute phaco time during phacoemulsification (p = 0.207) or in the three-month postoperative best corrected visual acuities among the three groups (p = 0.189). CONCLUSIONS: Importantly, there appears to be a significant correlation between alpha1AB and the development of IFIS. To prevent complications of IFIS, surgeons should be vigilant in identifying patients taking alpha1AB, checking the degree of preoperative pupil dilatation and anticipating intraoperative difficulties. In addition, appropriate modifications should be made to the surgical strategy. Furthermore there was no benefit to discontinuing alpha1AB treatment before cataract surgery in the prevention of IFIS.

A Case of Intraoperative Floppy Iris Syndrome in a Patient Using Tamsulosin

PURPOSE: To report a case of Intraoperative Floppy Iris Syndrome (IFIS) experienced during pars plana vitrectomy and phacoemulsification in a patient using tamsulosin, which is a selective alpha 1 adrenergic antagonist. CASE SUMMARY: A 77-year-old male who had used tamsulosin for the previous month for prostate cancer visited our clinic with left visual disturbance, that had developed a week earlier. The best-corrected visual acuity of the left eye was 0.02 and both pupils showed incomplete mydriasis. Pars plana vitrectomy and phacoemulsification with PCL implantation were performed on his left eye to correct a left cataract and retinal vein occlusion with vitreous hemorrhage. Phacoemulsification idenfied a billowing iris and progressive pupillary constriction. Therefore, we administered an intracameral epinephrine injection and applied an iris hook. The procedure was completed successfully without any complications. The best-corrected visual acuity of the left eye was good as at 0.9, and iris depigmentation and atrophy were checked two months postoperatively in the right eye, which had not had any previous surgical history. CONCLUSIONS: A detailed medical history taking is essential because IFIS may raise the risk of intraoperative complications, such as posterior capsule rupture, especially when the small pupil is small. Safe procedures must be planned with cessation of tamsulosin at least a week preoperatively.