Intra-operative floppy iris syndrome..IFIS

By Dr.shakhawan.A

Intraoperative floppy iris syndrome (IFIS) is a complication that may occur during cataract extraction in certain patients. This syndrome is characterized by a flaccid iris which billows in response to ordinary intraocular fluid currents, a propensity for this floppy iris to prolapse towards the area of cataract extraction during surgery, and progressive intraoperative pupil constriction despite standard procedures to prevent this.[

characterized by poor dilation of the pupil, intraoperative progressive miosis, billowing of the iris tissue, and iris prolapse through the ocular incisions during cataract surgery,IFIS has been associated with increased rates of surgical complications, including capsular rupture, vitreous loss, and the loss of iris tissue.

Induced primarily by the alpha 1-a inhibitor, tamsulosin (Flomax; Boehringer Ingelheim Pharmaceuticals, Inc.), IFIS may be associated with other alphablockers, psychotropic drugs, and over-the-counter agents such as saw palmetto. Tamsulosin is considerably more likely to induce IFIS than are other medications.

Flomax (tamsulosin), a medication widely prescribed for urinary symptoms associated with benign prostatic hyperplasia. Tamsulosin is a selective alpha blocker that works by relaxing the bladder and prostatic smooth muscle. As such, it also relaxes the iris dilator muscle by binding to its postsynaptic nerve endings.

IFIS may also be associated with other causes of small pupil like synechiae, pseudoexfoliation and other medications (used for conditions such as glaucoma, diabetes and high blood pressure). IFIS does not usually cause significant changes in postoperative outcomes. Patients may experience more pain, a longer recovery period, and less improvement in visual acuity than a patient with an uncomplicated cataract removal.

Management of IFIS (Intraoperative Floppy Iris Syndrome) An important part of the History is a medication history. During the preop exam, it is helpful to have patients bring a list of medications they are taking so that you can review it with them. We know that the effect of the alpha-1 blockers on the iris persists after discontinuing these drugs, so it is also necessary to specifically ask patients if they have ever taken one of these medications. In addition, it is helpful to evaluate the level of pupillary dilation during the fundus exam, as this may be an indicator of the severity of IFIS.

Various techniques for handling IFIS include preoperative topical atropine, intracameral epinephrine, Healon 5, iris hooks, and pupil expanders. Because of the spectrum of presentations of IFIS, these options do not always work equally well in all patients.

Atropine: Atropine bid or tid for 1-3 days prior to surgery may be helpful to achieve better dilation if it is noted that the patient dilates poorly during the exam.

Patients are also instructed to continue their tamsulosin therapy, due to the risk of acute urinary retention with the use of atropine

Epinephrine: Intracameral sulfite-free preservative-free epinephrine (dilution of the 1:1000 solution with BSS ranging from 1:3 to 1:5) may also help to further dilate the pupil.cause direct stimulation of iris dilator muscle

Healon 5 works very well to enlarge the pupil and stabilize the iris, but care must be used during hydrodissection and phacoemulsification to prevent blowing out the posterior capsule and creating a wound burn, respectively.

Iris hooks and pupil expanders: These devices are 100% effective at enlarging the pupil and they also stabilize the iris.

If you are having difficulty with iris hooks, it may help to do one or more of the following: create the stab incisions as peripheral and parallel to the iris plane as possible, only partially fill the anterior chamber with OVD prior to placing the hooks, and use a hook under/behind the cataract incision. Pupil expanders do not require separate incisions and can be inserted more rapidly. Do not distort the shape or position of iris.