Intraoperative floppy iris syndrome associated with tamsulosin

Clinical experience with intraoperative floppy-iris syndrome. Results of the 2008 ASCRS member survey

According to an online survey, most members of the American Society of Cataract and Refractive Surgery believe that tamsulosin makes cataract surgery more difficult (95%) and increases the risks of surgery (77%). Commonly reported complications of intraoperative floppy-iris syndrome (IFIS) were significant iris trauma and posterior capsule rupture, with 52% and 23% of respondents, respectively, reporting these complications at a higher rate than in non-IFIS eyes. There was no single preferred surgical method for managing IFIS; 33% of respondents routinely used multiple strategies. Of respondents with sufficient experience, 90% believe that IFIS is more likely with tamsulosin than with nonspecific alpha1-antagonists. Ninety-one percent believe that physicians prescribing alpha1-antagonists should become better educated about IFIS, and 59% would recommend a pretreatment ophthalmic evaluation for patients with cataracts or decreased vision. If they themselves had mildly symptomatic cataracts, 64% of respondents would avoid taking tamsulosin or would have their cataract removed first.

Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: results in 30 consecutive cases

PURPOSE

To evaluate a new disposable, small-pupil expansion device in tamsulosin patients with intraoperative floppy-iris syndrome (IFIS) having cataract surgery.

SETTING

Private practice, Los Altos, California, USA.

METHODS

The 5-0 polypropylene Malyugin pupil expansion device (MicroSurgical Technology) was used in 30 eyes from 21 tamsulosin patients having routine cataract surgery. The pupil diameter was measured at the beginning and end of surgery, and the severity of IFIS was graded. Intraoperative and postoperative complications were recorded.

RESULTS

The device maintained a constant 6.0 mm pupil diameter throughout surgery. Although iris prolapse was still possible, there were no significant intraoperative or postoperative complications despite the fact that 93% of the eyes had moderate to severe IFIS. All eyes achieved a best corrected visual acuity of at least 20/25. There was a tendency for ring deformation if flash sterilization was used without sufficient cooling time.

CONCLUSIONS

The disposable Malyugin pupil expansion device was highly effective at maintaining an adequate pupil opening in eyes with IFIS. It is easier and faster to use than iris retractors and other pupil expansion rings and represents an excellent small-pupil strategy.

Intraoperative floppy iris syndrome associated with alpha1-adrenergic receptor antagonists

OBJECTIVE

To describe intraoperative floppy iris syndrome (IFIS) in association with alpha(1)-adrenergic receptor (alpha(1)AR) antagonists by conducting a thorough literature review.

DATA SOURCES

Literature retrieval was accomplished by searching MEDLINE (2000-December 2007) using the terms intraoperative floppy iris syndrome (IFIS), adrenergic alpha-antagonist(s), tamsulosin, doxazosin, terazosin, and/or alfuzosin. In addition, reference lists from identified publications were reviewed to identify additional reports and studies of interest.

STUDY SELECTION AND DATA EXTRACTION

All articles in English identified from data sources were reviewed for relevance and uniqueness prior to inclusion.

DATA SYNTHESIS

IFIS was first described in 2005 as a clinical triad observed during cataract surgery that includes fluttering and billowing of the iris stroma, propensity for iris prolapse, and constriction of the pupil. IFIS increases the risk of complications during cataract surgery. Numerous reports have linked IFIS to use of alpha(1)AR antagonists, most notably tamsulosin, which is prescribed for benign prostatic hyperplasia. Tamsulosin blocks prostatic alpha(1A)ARs but may also selectively block alpha(1A)ARs in the iris dilator muscle, preventing mydriasis during cataract surgery. Other alpha(1)AR antagonists, including terazosin, doxazosin, and alfuzosin, have also been linked to IFIS; however, their relationship to the syndrome is not as definitive. When ophthalmologists are aware of a patient's previous alpha(1)AR antagonist exposure, specific steps can be taken to reduce the risk of surgical complications. Corrective measures used during surgery have included iris expansion hooks, intracameral phenylephrine, and preoperative atropine.

CONCLUSIONS

IFIS is a clinical syndrome observed during cataract surgery reported in patients taking systemic alpha(1)AR antagonists. It has been most strongly linked to use of tamsulosin. Medication washout periods of up to 2 weeks and specific surgical procedures have been attempted to reduce risk of complications from alpha(1)AR antagonists in the setting of cataract surgery. Patients should be educated regarding potential risks of this drug class so that they can discuss them with their healthcare providers, specifically ophthalmologists, prior to cataract surgery.

Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin

PURPOSE

To evaluate the intraoperative findings, complication rates, effect of intracameral adrenaline, and incidence of intraoperative floppy iris syndrome (IFIS) in patients using tamsulosin.

METHODS

In this prospective nonrandomized observational study, 858 eyes of 774 patients who had phacoemulsification between August 2005 and November 2006 were evaluated. Duration and preoperatively discontinuing time of tamsulosin intake were questioned. Preoperative pupil size, intraoperative iris behavior, progressive miosis, adrenalin usage, and complications were recorded.

RESULTS

The incidence of IFIS was 1.6% and IFIS was seen in 14 of the 18 eyes of patients using tamsulosin (77.8%). One eye had floppy iris only, 2 eyes had floppy iris and intraoperative miosis, 3 eyes had floppy iris and iris prolapse, and 8 eyes had all three signs of IFIS. IFIS was seen in 7 of the 10 eyes where intracameral adrenaline was used, and in 7 of the 8 eyes without adrenaline (p=0.588). Intraoperative miosis was seen only in 3 of the 10 eyes with adrenaline and in 7 of the 8 eyes without adrenaline (p=0.025). Posterior capsule rupture occurred in 1 of the eyes with IFIS and in 5 eyes focal iris stromal atrophy caused by prolapse was seen.

CONCLUSIONS

IFIS occurred in 1.6% of cases having phacoemulsification. Intracameral adrenaline usage did not change the IFIS occurrence rate, but it seemed to be effective in preventing intraoperative miosis. There are still many questions about IFIS, and there is need for future studies strengthening the understanding of IFIS.

Cataract surgery using the bimanual phacoemulsification technique with an Accurus system and Mackool microphaco tip

PURPOSE

To investigate the safety and effectiveness of the Accurus vitreoretinal and phacoemulsification system (Alcon, Inc.) for bimanual phacoemulsification surgery.

SETTING

Kosei Chuo Hospital, Tokyo, Japan.

METHODS

Phacoemulsification for age-related cataract was performed using a bimanual technique in 55 eyes and a coaxial technique in 31 eyes. The Accurus system with a venturi pump and a sleeveless ultrasonic tip or a Mackool microphaco tip was used in all cases. The 2 techniques were compared. In bimanual phacoemulsification, the 2 tips were evaluated to determine whether either reduced ocular tissue impairment.

RESULTS

The mean best corrected visual acuity 1 day after the surgery was 20/20 in both groups. There was no significant difference between the bimanual group and coaxial group except in ultrasound output (bimanual 22%, coaxial 28%; P = .01). Iris impairment was observed only in the bimanual group but was reduced by the use of the Mackool sleeved microphaco tip.

CONCLUSION

Bimanual phacoemulsification for cataract surgery using the Accurus system with a venturi pump and a Mackool microphaco tip was safe and effective and may provide a means of performing combined or successive cataract and vitreoretinal surgery.

Postoperative finding in the intraoperative floppy-iris syndrome

We describe a postoperative finding discovered before surgery in the second eye of a patient who had intraoperative floppy-iris syndrome (IFIS). Recognizing the risk for IFIS is important to anticipate and manage the syndrome and ensure successful cataract surgery. Obtaining the right information about the past and present intake of alpha-blockers is mandatory.

Pediatric intraoperative floppy-iris syndrome

We report an unusual intraoperative finding in the case of a 4-month-old infant with bilateral congenital cataracts removed within a 1-week period. Surgery in the right eye was uneventful. During removal of the cataract in the left eye, signs of the intraoperative floppy-iris syndrome (IFIS) were observed; ie, iris floppiness, iris prolapse to the incisions, and progressive miosis. The surgical technique was identical in both eyes except that epinephrine was added to the irrigating solution in the right eye but inadvertently omitted in the left-eye surgery. Use of intracameral epinephrine has been documented to prevent IFIS in adult eyes at risk for developing the syndrome. Our case highlights the importance of epinephrine in the irrigating solution in pediatric cataract surgery.

Pharmacology of α1-adrenoceptor antagonists in the lower urinary tract and central nervous system

The main use of alpha(1)-adrenoceptor (AR) antagonists in urology has been to treat lower urinary tract symptoms (LUTS) in men with benign prostatic obstruction (BPO). The beneficial effects of these agents are primarily assumed to be because of relaxation of prostatic and urethral smooth muscle. The weak correlation between LUTS and prostatic enlargement, outflow obstruction, or both, however, has refocused interest on the role of extraprostatic alpha-ARs in the pathogenesis of LUTS and their treatment. The alpha(1)-ARs present in the bladder, urethra, vas deferens, peripheral ganglia, nerve terminals, and in the central nervous system could all potentially influence LUTS and, when the receptors are blocked, contribute to both the therapeutic and adverse effects of alpha(1)-AR antagonists. The relevance of alpha(1)-AR-subtype selectivity on the clinical usefulness of existing drug therapies has not been firmly established but it seems that blockade of both alpha(1A/L)- and alpha(1D)-ARs is necessary for the optimum balance between clinical efficacy and adverse effects.

Intraoperative floppy-iris syndrome associated with α1-adrenoreceptors

PURPOSE

To compare the incidence of intraoperative floppy-iris syndrome (IFIS) in men exposed to tamsulosin and men exposed to alfuzosin and evaluate the effect of IFIS on the complication rate of cataract surgery.

SETTING

Tertiary care hospital, Chicoutimi, Quebec, Canada.

METHODS

The medical charts of 64 men (92 eyes) who had phacoemulsification cataract surgery between June 2005 and July 2006 and reported having used tamsulosin or alfuzosin at their initial visit for cataract evaluation were reviewed. The presence or absence of IFIS, potential confounding clinical covariates, duration of surgery, and complications were noted. The history of taking an alpha1-antagonist was verified. To address the main objective of the study, only patients who had exclusively used tamsulosin or alfuzosin were included. For the secondary objective, all eligible patients were included even if they had received more than one alpha1-antagonist in the past.

RESULTS

Of men exclusively exposed to tamsulosin (22) or alfuzosin (13), 86.4% and 15.4%, respectively, developed IFIS (P<.001). The adjusted odds ratio of IFIS in patients exposed to tamsulosin compared to those exposed to alfuzosin was 32.15 (95% confidence interval, 2.74-377.11). Eyes with IFIS had a higher risk for complications (focal iris stromal atrophy, transient postoperative hypertension, major iris trauma, posterior capsule break with vitreous loss, zonular dehiscence, postoperative cystoid macular edema) than eyes without IFIS (P<.001).

CONCLUSIONS

Men exposed to tamsulosin had a significantly higher risk for developing IFIS than men exposed to alfuzosin. Intraoperative floppy-iris syndrome significantly increased the complication rate of cataract surgery.

Intraoperative floppy-iris syndrome: Do we know everything about it?

We report a case of bilateral phacoemulsification for nuclear cataract in a 76-year-old man. The patient took tamsulosin for 4 months and stopped the medication 1 year before the cataract surgery. Phacoemulsification in the left eye was uneventful. One week later, phacoemulsification was performed in the same manner in the right eye, which demonstrated the 3 signs of the intraoperative floppy-iris syndrome (IFIS). Postoperative examinations revealed iris stromal atrophy and an irregular pupil in this eye. This case raises many questions: Why was IFIS seen in 1 eye only? Is the intake and stopping time of tamsulosin important to the occurrence of IFIS? Is intracameral adrenaline effective in preventing IFIS? Future studies are needed to increase our understanding of IFIS.

The Long-Term Outcome of Medical Therapy for BPH

OBJECTIVES

The lack of cure with medical therapy implies life-long treatment emphasising the need for a thorough understanding of the long-term outcome. We review the natural history, markers for progression, placebo effect, efficacy, pharmacoeconomic aspects, and preventive measures.

METHODS

Literature review with particular reference to long-term controlled studies using plant extracts, alpha1-blockers, 5alpha-reductase inhibitors (5-ARIs), and combination therapy.

RESULTS

There is a long-lasting (>or=12 mo) placebo response of symptoms (20% decrease) and maximum flow rate (10% rise). The five long-term controlled trials of plant extracts are inconclusive and therefore their role in contemporary medical management is still controversial. The alpha1-blockers provide fast amelioration of symptoms yet have no relevant impact on the risk of acute urinary retention or surgery. Combination therapy should be reserved for moderately or severely symptomatic patients with a high risk of progression; in the majority of patients the alpha1-blocker can be safely stopped after 6-12 mo. The preventive use of 5-ARIs in men with no or mild symptoms at risk of progression is scientifically sound yet not generally accepted mainly for economic reasons.

CONCLUSIONS

A sharp contrast exists between the duration of the longest controlled trial (4.5 yr) and the situation in real life with treatment periods up to one or two decades of life. Real-life and registry data will be the only source of this important information in the future.

Prospective Multicenter Evaluation of Cataract Surgery in Patients Taking Tamsulosin (Flomax)

PURPOSE

Intraoperative floppy iris syndrome (IFIS) caused by systemic alpha-blockers has been associated with an increased risk of cataract surgical complications when the surgeon was unaware of the medication history and did not anticipate its occurrence. This study was undertaken to evaluate the surgical outcomes and rate of complications when the ophthalmologist knew the patient was taking tamsulosin (Flomax, Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT) and used 1 of several strategies to manage IFIS.

DESIGN

Prospective multicenter nonrandomized observational series.

PARTICIPANTS

A total of 167 consecutive eyes in 135 patients taking tamsulosin and undergoing cataract surgery.

METHODS

Phacoemulsification was performed in conjunction with at least 1 of 4 different IFIS management strategies, namely, topical atropine preoperatively, iris retractors, pupil expansion ring, or use of viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters.

MAIN OUTCOME MEASURES

Severity of IFIS, incidence of operative or postoperative complications, and final visual acuity.

RESULTS

The IFIS severity was rated as mild in 17%, moderate in 30%, and severe in 43% of the study eyes. No IFIS was noted in 10% of the eyes. The rate of posterior capsule rupture and vitreous loss was 0.6% (1/167; 95% confidence interval, 0%-1.8%). Ninety-five percent of eyes achieved a best-corrected visual acuity of at least 20/40.

CONCLUSION

When experienced surgeons could anticipate IFIS and employ compensatory surgical techniques, the complication rate from cataract surgery was low and the visual outcomes were excellent in eyes of patients with a history of tamsulosin use.

Combined preoperative topical atropine sulfate 1% and intracameral nonpreserved epinephrine hydrochloride 1:2500 for management of intraoperative floppy-iris syndrome

We describe a technique combining preoperative atropine sulfate 1% and intraoperative intracameral epinephrine in a 1:2500 dilution for the management of intraoperative floppy-iris syndrome (IFIS) induced by alpha(1A)-blocking agents such as tamsulosin. Patients on alpha(1A)-blocking agents used topical atropine sulfate 1% 3 times a day for 2 days before surgery. In addition to routine topical mydriatics before surgery, they received intracameral epinephrine diluted 1:2500 with BSS. In 19 of 20 eyes, there were no clinical manifestations of IFIS with this regimen. Stimulation of the iris dilator by a direct-acting sympathomimetic (epinephrine) combined with strong pupiloplegia (atropine) provides powerful synergism. Preoperative identification of patients on alpha(1)-blockers is important as complications can be reduced significantly by using appropriate strategies to deal with this condition. It is also important that patients suffering from benign prostatic hyperplasia do not stop using an alpha(1A)-blocker, especially when preoperative atropine is used, as acute urinary retention may ensue.

The effects of two systemic α1-adrenergic blockers on pupil diameter: a prospective randomized single-blind study

Our aim was to investigate the effects of two alpha(1)-adrenergic blockers-tamsulosin and alfuzosin-on pupil diameter (PD). In this prospective randomized single-blind clinical trial, 64 patients with benign prostatic hyperplasia received treatment with either tamsulosin or alfuzosin. The same ophthalmologist, masked to the given medication, evaluated patients prior to, 4 weeks after and 6 months after the start of the medication (day 0, day 28 and month 6). Best corrected visual acuity and PD under mesopic, scotopic, and dilated conditions were measured. t-test, ANOVA, and Dunnett's multiple comparison post-test were used for statistical analysis. With tamsulosin treatment, both mesopic and scotopic PD decreased, respectively, from 3.9 +/- 0.7 and 5.7 +/- 0.6 mm at day 0 to 3.6 +/- 0.9 and 5.5 +/- 0.8 mm at day 28, and 3.6 +/- 0.7 and 5.4 +/- 0.7 mm at month 6 (ANOVA; P = 0.021 and = 0.040, respectively). However, the difference in dilated PD was not significant (day 0 7.8 +/- 0.6 mm, day 28 7.7 +/- 0.7 mm, and month 6 7.6 +/- 0.6 mm, P = 0.379). In the alfuzosin group, PD did not differ significantly from the baseline except for the scotopic measurements, which decreased from 5.6 +/- 0.6 mm at day 0 to 5.5 +/- 0.6 mm at day 28 and 5.2 +/- 0.8 mm at month 6 (P = 0.004). Compared to baseline values, small but statistically significant decreases were detected in mesopic and scotopic illumination in patients treated with tamsulosin and in scotopic PD in patients treated with alfuzosin. The clinical significance of these differences needs further evaluation.

Adjunct devices for managing challenging cases in cataract surgery: pupil expansion and stabilization of the capsular bag

PURPOSE OF REVIEW

Patients anticipate favorable surgical outcomes when having cataract surgery. The modern-day cataract surgeon should employ all necessary means to achieve this result. A working knowledge of adjunct devices for pupil expansion and capsular-bag stabilization can significantly improve surgical outcomes.

RECENT FINDINGS

Adjunct devices for pupil expansion include the Beehler pupil dilator, nylon iris hooks, and pupillary rings, including the Perfect Pupil, the Graether 2000, and the Morcher pupil dilator. Capsular-bag stabilization can be accomplished with capsular tension rings, capsular tension segments or iris hooks. The recent literature on these devices is reviewed.

SUMMARY

Impaired visualization through a small pupil and poor tissue stabilization increases the chance of tissue damage, retained nuclear material, and vitreous loss. Fortunately, inadequate mydriasis and instability of the capsular bag can be managed safely with the use of adjunct tools. Preoperative planning, familiarity with available tools, and accessibility of these devices in the operative setting is necessary.

Choroidal detachment following the use of tamsulosin (Flomax)

PURPOSE

To report choroidal detachment following tamsulosin (Flomax, an alpha(1A)-adrenoceptor antagonist) treatment of benign prostatic hyperplasia (BPH).

DESIGN

Case report.

METHODS

Chart review, serial examination.

RESULTS

A 65-year-old man underwent uncomplicated cataract extraction and placement of a posterior chamber intraocular lens. The patient subsequently developed three separate episodes of choroidal detachments in the operated eye. Each episode was preceded by treatment with an alpha(1)-adrenoceptor antagonist.

CONCLUSIONS

Tamsulosin may cause adverse ocular effects including recurrent choroidal detachments. alpha(1A) is the dominant alpha-adrenoceptor in the rabbit choroid, and the mechanism for choroidal detachment in this patient could include some effect of antagonists like tamsulosin on these receptors.

Floppy iris behaviour during cataract surgery: associations and variations

AIM

To assess the association of floppy iris behaviour during cataract surgery with use of alpha-1-antagonists and diabetes mellitus.

METHODS

1842 eyes of 1786 patients undergoing phacohoemulsification surgery were prospectively enrolled. The use of commonly prescribed alpha-1-antagonists and the presence or absence of diabetes mellitus were noted. The occurrence of any of the features of the intraoperative floppy iris syndrome (IFIS) was noted by surgeons blinded to the patient's history.

RESULTS

57% of patients receiving tamsulosin showed features of IFIS compared with 1% of the non-tamsulosin group (p<0.001). Of these, more than half the patients manifested the syndrome in an incomplete form. Only 1 of the 51 patients receiving other alpha-1-antagonists had IFIS. Diabetes was also not associated with IFIS (p = 1).

CONCLUSIONS

Tamsulosin is significantly associated with floppy iris behaviour during cataract surgery. But not all of these patients will necessarily show all or any features of IFIS. The floppy iris syndrome is likely to represent a continuum of severity. Various undefined factors, diabetes not being one of them, may have a contributory role. Non-selective alpha-1-antagonists are unlikely to be associated with IFIS.