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Kaur S, Kumari K, Gupta PC, Sukhija J. Pharmacological management of intra-operative miosis during cataract surgery. Indian J Ophthalmol 2023; 71:2656-2661. [PMID: 37417103 PMCID: PMC10491068 DOI: 10.4103/ijo.ijo_3384_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 07/08/2023] Open
Abstract
Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.
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Affiliation(s)
- Savleen Kaur
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Kumari
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parul Chawla Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaspreet Sukhija
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Pearls for the young cataract surgeon: the pupil of concern. J Cataract Refract Surg 2023; 49:117-118. [PMID: 36700886 DOI: 10.1097/j.jcrs.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Gowda A, Jie WWJ, Casson R, Chan WO. The safety of intracameral phenylephrine - A systematic review. Surv Ophthalmol 2022; 67:1540-1546. [PMID: 35691387 DOI: 10.1016/j.survophthal.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/28/2022] [Accepted: 06/06/2022] [Indexed: 10/18/2022]
Abstract
Intracameral phenylephrine is commonly used in ophthalmic surgery as an alternative or supplement to mydriatic eye drops; hence, the importance of an evidence-based understanding of its risk-benefit profile is vital. We performed a comprehensive search in the PubMed, Google Scholar and Cochrane databases for published studies and case reports relating to the use of intracameral phenylephrine. Articles from 1958 to 2021 with the following keywords were used: "intracameral phenylephrine", "intracameral mydriatics", "phenylephrine", "pupil dilation", "complications". Intracameral phenylephrine was first used in 2003 as an alternative to topical mydriatics. Since then, it is being increasingly used with a variety of benefits, including rapid onset of mydriasis, and cost-effectiveness. There are various case reports, however, of ocular and systemic complications associated with intracameral phenylephrine such as generation of free radicals, toxic anterior segment syndrome, inconsistent pupillary dilation during surgery, and ventricular fibrillation. Alternatives to intracameral phenylephrine such as iris hooks, a Malyugin ring, intracameral epinephrine, and intracameral tropicamide were compared with intracameral phenylephrine. Intracameral phenylephrine appears to have a good safety profile.
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Affiliation(s)
- Akash Gowda
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia.
| | - Wilson Wong Jun Jie
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia; Tun Hussein Onn National Eye Hospital, Selangor, Malaysia
| | - Robert Casson
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia
| | - Weng Onn Chan
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia
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Kwak J, Han JY, Moon SY, Nam S, Kim JY, Tchah H, Lee H. Relationship Between Tamsulosin Use and Surgical Complications of Cataract Surgery in Elderly Patients: Population-Based Cohort Study. Front Med (Lausanne) 2022; 9:882131. [PMID: 35665322 PMCID: PMC9160597 DOI: 10.3389/fmed.2022.882131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Although several previous studies have investigated the relationship between tamsulosin use and surgical complications of cataract surgery, no population-based cohort study has been conducted for the Asian population. We aimed to investigate the relationship between tamsulosin use and surgical complications of cataract surgery in the Korean elderly population. Methods This nationwide population-based retrospective cohort study included elderly patients (≥60 years) who had undergone cataract surgery in the period from 2003 to 2015. Baseline characteristics were age, sex, income, residence, and systemic, and ocular comorbidities (glaucoma, myopia, eye trauma, diabetes mellitus with ophthalmic manifestations, severe cataract, age-related macular degeneration). The exposure of interest was tamsulosin use within 1 year before cataract surgery. Logistic regression model was used to evaluate the relationship of tamsulosin use with surgical complications of cataract surgery. Results The rate of surgical complications of cataract surgery was 0.88% (375/42,539) in the non-tamsulosin group and 0.83% (71/8,510) in the tamsulosin group. The groups showed no significant difference in the risk of surgical complications of cataract surgery in the unadjusted model [odds ratio (OR) = 0.946; 95% confidence interval (CI):0.733–1.220; P = 0.669]. Additionally, tamsulosin use was not significantly associated with surgical complications of cataract surgery in the fully adjusted model accounting for age, income, residence, and systemic and ocular comorbidities (OR = 0.997; 95% CI: 0.749–1.325; P = 0.981). Conclusions The rate or risk of surgical complications of cataract surgery does not change with tamsulosin use. We suggest that better surgical techniques and surgeons' cognizance of the patient's tamsulosin use could improve surgical outcomes, without increasing surgical complications.
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Park SSE, Wilkinson S, Mamalis N. Dealing with floppy iris syndrome. Curr Opin Ophthalmol 2022; 33:3-8. [PMID: 34711714 DOI: 10.1097/icu.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review and summarize recent findings and advancements regarding intraoperative floppy iris syndrome (IFIS). Although many improvements have been made for the management of IFIS, it remains a challenging condition for surgeons. An understanding of the syndrome as well as the multitude of tools to mitigate risk of complication is important for surgeons operating on high-risk patients. RECENT FINDINGS A variety of management approaches have been modified and improved or further supported with new data, such as intracameral compounds, intraoperative devices and surgical techniques. SUMMARY An understanding of risk factors is important for the identification of at-risk patients. A variety of approaches can greatly reduce incidence of IFIS complications. Multiple management strategies should be utilized to further reduce risk during these difficult surgeries.
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Affiliation(s)
- Sally S E Park
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
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Outcomes of first 50 cases using a new pupil expander. J Cataract Refract Surg 2021; 47:1122-1126. [PMID: 34468448 DOI: 10.1097/j.jcrs.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the initial experience with the Assia Pupil Expander 200 (APX-200, APX Ophthalmology) in eyes that underwent phacoemulsification or intraocular lens repositioning surgery that required mechanical pupil expansion. SETTING Department of Ophthalmology, Meir Medical Center, Kfar-Saba, and Ein-Tal Eye Center, Tel Aviv, Israel. DESIGN Retrospective case series. METHODS The APX-200 is a single-use device, intended for mechanical expansion of the pupil during intraocular surgery. Two devices are inserted through 2 opposite 19-gauge incisions using designated forceps. The surgical course and early postoperative follow-up was recorded in 50 eyes. RESULTS The study included 50 consecutive eyes, with mean preoperative pupil diameter was 3.7 mm. The APX effectively dilated the pupils in all cases. No complication related to the use of the APX such as hyphema, iridodialysis, or Descemet membrane detachment were noted in this series. A central and round pupil was restored in all eyes at 1-month postoperatively, with 14 eyes (28%) having mild sphincter tears. Pupilloplasty was not required in any of the cases. CONCLUSIONS The APX-200 was an effective and safe device for pupil expansion during intraocular surgery.
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Tobaiqy M, Aalam W, Banji D, Al Haleem ENA. Intraoperative Floppy Iris Syndrome Induced by Tamsulosin: The Risk and Preventive Strategies. Middle East Afr J Ophthalmol 2021; 28:51-56. [PMID: 34321822 PMCID: PMC8270016 DOI: 10.4103/meajo.meajo_561_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/04/2022] Open
Abstract
Tamsulosin is an antagonist of a subtype-specific alpha-1A- and alpha-1D-adrenoceptor (AR) that is expressed in the prostate gland, urethra, and bladder. Several reports have shown a possible relationship between ophthalmologic adverse effects and the use of alpha-1-receptor medicines, including tamsulosin. This descriptive review evaluates the intraoperative floppy iris syndrome (IFIS) associated with tamsulosin. A search of the Medline and PubMed databases was conducted to identify control trials, case reports, and observational examinations published in English. The publication dates were restricted (January 1, 2000, to January 1, 2020). Keywords (tamsulosin, alpha-blocker, ocular, eye, adverse reaction, and IFIS) were used in the searches. The searches identified 66 studies including in vitro or in vivo studies, trials, and observational studies. Twenty-two (33.33%) studies were articles citing tamsulosin and IFIS as having confirmed potential risk to ocular safety. The results of this review, including a comprehensive summary of published research on tamsulosin use in different populations, have identified several articles showing associations between tamsulosin and IFIS that merit further investigation. Suspending of potential causative pharmacological treatment of IFIS before ocular surgery including tamsulosin, proper identification of at-risk patients, preoperative prophylaxis treatments, and surgical technique modifications clearly can mitigate the anticipated risk of IFIS induced by tamsulosin.
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Affiliation(s)
- Mansour Tobaiqy
- Department of Pharmacology, College of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Waseem Aalam
- Department of Ophthalmology, College of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - David Banji
- Department of Pharmacy Practice, Pharmacy Practice Research Unit, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Ekram N Abd Al Haleem
- Department of Pharmacology and Toxicology, College of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt
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Tzamalis A, Christou CD, Tsinopoulos I, Ziakas N. Risk factors of floppy iris syndrome: current insights. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1877539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Argyrios Tzamalis
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki Papageorgiou General Hospital, Thessaloniki, Greece
| | - Chrysanthos D. Christou
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioannis Tsinopoulos
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Ziakas
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki Papageorgiou General Hospital, Thessaloniki, Greece
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Kaur M, Bhai N, Titiyal JS. Risk factors for complications during phacoemulsification cataract surgery. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1806715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Manpreet Kaur
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Nithya Bhai
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S. Titiyal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Pupil expansion device use and operative outcomes with topical dilation vs intracameral epinephrine in resident-performed cataract surgery. J Cataract Refract Surg 2020; 46:562-566. [PMID: 32271295 DOI: 10.1097/j.jcrs.0000000000000106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the use of topical dilation drops vs topical drops with the addition of intracameral epinephrine in resident-performed cataract surgery and the effects on pupil expansion device (PED) use, surgical costs, and surgical times. SETTING Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA. DESIGN Retrospective chart review. METHODS Resident-performed primary cataract surgical cases using topical dilation drops only or drops with the addition of intracameral epinephrine were analyzed for PED use, surgical time, and costs in all patients and in patients with a history of tamsulosin use. RESULTS In the topical group, PEDs were used in 31.1% of cases compared with 13.5% of cases in the intracameral group (P < .0001). History of tamsulosin use was noted in about one third of cases in both groups. For patients with a history of tamsulosin use, PED use decreased from 52.7% in the topical cases to 17.9% in the intracameral group (P < .0001). Surgical times were on average 7.1 minutes slower with PED use than without PED use. There was a medication savings of $50.44 USD per case in the intracameral group compared with the topical group. Factoring in the $100 to $130 USD per PED used, total surgical costs were $19 267 USD less in the intracameral group over 6 months. CONCLUSIONS Intracameral epinephrine with lidocaine decreases the need for PED use during cataract surgery, lowers intraoperative costs, and improves efficiency compared with topical dilation drops alone.
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Christou CD, Tsinopoulos I, Ziakas N, Tzamalis A. Intraoperative Floppy Iris Syndrome: Updated Perspectives. Clin Ophthalmol 2020; 14:463-471. [PMID: 32109982 PMCID: PMC7039091 DOI: 10.2147/opth.s221094] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/11/2020] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Chrysanthos D Christou
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioannis Tsinopoulos
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Ziakas
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Argyrios Tzamalis
- 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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Abstract
PURPOSE OF REVIEW Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence. RECENT FINDINGS Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved. SUMMARY Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.
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Affiliation(s)
- Neal H Shorstein
- Departments of Ophthalmology and Quality, Shorstein - Kaiser Permanente, Oakland, California; Department of Ophthalmology, Myers - Northwestern University, Chicago, IL
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LoBue SA, Tailor P, LoBue TD. A Simple, Novel Approach to Capsulorhexis Formation in the Setting of A Mature Cataract and Miotic Pupil. Clin Ophthalmol 2019; 13:2361-2367. [PMID: 31819361 PMCID: PMC6896912 DOI: 10.2147/opth.s220731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/08/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To report a simple, effective technique for surgeons creating a capsulorhexis in patients with pupillary miosis and a dense, mature cataract. Methods A single center, two-year retrospective chart review examined 1408 phacoemulsification cataract surgeries. The criteria for inclusion involved a dense, mature cataract and a pupil that was unresponsive to pharmacologic dilation preoperatively. A standardized technique was used for all cases consisting of a 1mm corneal paracentesis and 2.4mm temporal clear corneal incision. Synecholysis was performed if present, followed by the insertion of a 6.25mm malyugin ring under cohesive viscoelastic. The cohesive viscoelastic was removed via the irrigation aspiration tip. The paracentesis was sealed with a small amount of viscoelastic and an air bubble was placed in the anterior chamber. The anterior capsule was then painted with trypan blue. The air bubble and trypan blue were then replaced by a dispersive viscoelastic. Curvolinear capsulorrhexis was performed followed by standard phacoemulsion. Results Nine patients ranging from 76 ± 12 years (mean ± standard deviation) met the criteria with a 4+ NS (n=5), white mature (n=3), or deep brunescent (n=1) cataract and 3mm pupil preoperatively. Pupillary miosis was caused by posterior synechia in 44.5% of the cases followed by pharmacologic interactions from tamsulosin and donepezil in 22.25% of cases respectively. One case involved idiopathic miosis likely from aging. Capsulorhexis formation was successful in all cases with no capsular tear, vitreous loss, or conversion to extracapsular cataract extraction (ECCE). However, one case had cortex retention requiring a second procedure for removal. Conclusion Dense, mature cataracts and small pupils both compromise the view for the surgeon and may be significant risk factors for training ophthalmologists. Thus, good visualization of the anterior capsule and peripheral nucleus with our simple technique facilitates a reliable capsulorhexis, potentially limiting the risk of complications for ophthalmic surgeons.
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Affiliation(s)
- Stephen A LoBue
- Department of Ophthalmology, LoBue Laser and Eye Medical Center Inc, Murrieta, CA, USA.,Lincoln Medical Center, Affiliated to Weill Cornell Medical College, Bronx, NY, USA
| | | | - Thomas D LoBue
- Department of Ophthalmology, LoBue Laser and Eye Medical Center Inc, Murrieta, CA, USA
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Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell EDL, Hooper PL, Bell CM, ten Hove MW. Evolution in the Risk of Cataract Surgical Complications among Patients Exposed to Tamsulosin. Ophthalmology 2019; 126:490-496. [DOI: 10.1016/j.ophtha.2018.11.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/29/2022] Open
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Moustafa GA, Borkar DS, McKay KM, Eton EA, Koulisis N, Lorch AC, Kloek CE. Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study. J Cataract Refract Surg 2018; 44:1469-1477. [PMID: 30391157 DOI: 10.1016/j.jcrs.2018.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/16/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons. SETTING Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. DESIGN Retrospective chart review. METHODS 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. RESULTS 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 group 1 month 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 ± 26.5 minutes and 30.9 ± 12.6 minutes 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). CONCLUSION 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.
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Affiliation(s)
- Giannis A Moustafa
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - Durga S Borkar
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - K Matthew McKay
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - Emily A Eton
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - Nicole Koulisis
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - Alice C Lorch
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
| | - Carolyn E Kloek
- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA.
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- From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA
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Al-Hashimi S, Donaldson K, Davidson R, Dhaliwal D, Jackson M, Kieval JZ, Patterson L, Stonecipher K, Hamilton DR. Medical and surgical management of the small pupil during cataract surgery. J Cataract Refract Surg 2018; 44:1032-1041. [DOI: 10.1016/j.jcrs.2018.02.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/23/2018] [Accepted: 02/28/2018] [Indexed: 10/28/2022]
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Esen F, Bulut AE, Toker E. Efficacy and safety of low-concentration, bisulphite-containing, intracameral epinephrine and topical atropine treatments for the prevention of intraoperative floppy iris syndrome. Cutan Ocul Toxicol 2018; 37:286-290. [PMID: 29606019 DOI: 10.1080/15569527.2018.1456448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy and safety of topical atropine and topical atropine combined with intracameral low-concentration, bisulphite-containing epinephrine treatment for the prophylaxis of intraoperative floppy iris syndrome. MATERIALS AND METHODS Seventy-two eyes of 55 male patients who were treated with alpha-adrenergic antagonist medications for benign prostatic hyperplasia were included in this study. Standard premedication with topical cyclopentolate, phenylephrine, tropicamide and ketorolac was applied to all of the patients. In 22 cases no further prophylactic method was used (Group-NP), while in 29 cases topical atropine drops was instilled 12 h and 30 min before surgery (Group-A) and in 21 cases 1:16 000 epinephrine was injected to the anterior chamber at the beginning of surgery (Group-EA) in addition to topical atropine prophylaxis. RESULTS In Group-NP, 62.8% of the cases developed IFIS, while development of IFIS was significantly lower in Group-A (17.2%, p = 0.0004) and Group-EA (9.5%, p < 0.0001). Posterior capsule rupture was observed in two cases (9.1%) in Group-NP, in one case (3.4%) in Group-A and was not observed in Group-EA. There was no statistically significant difference between the groups for the development of surgical complications. We did not observe any adverse events or significant endothelial cell loss (p = 0.462). CONCLUSIONS Our results indicate that preoperative use of topical atropine reduces the incidence of IFIS. Use of low-concentration, bisulphite-containing epinephrine is more effective in the prevention of IFIS and does not cause preservative related endothelial damage. This prophylaxis may be preferred when preservative free epinephrine is not available.
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Affiliation(s)
- Fehim Esen
- a Department of Ophthalmology , Istanbul Medeniyet University School of Medicine , Istanbul , Turkey
| | | | - Ebru Toker
- c Department of Ophthalmology , Marmara University School of Medicine , Istanbul , Turkey
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Nuzzi R, Arnoffi P, Tridico F. Best Prophylactic Strategy in Groups at Risk of Intraoperative Floppy Iris Syndrome Development: Comparison Between Atropine Instillation and Adrenaline Intracameral Injection. Open Ophthalmol J 2018; 12:34-40. [PMID: 29760826 PMCID: PMC5897993 DOI: 10.2174/1874364101812010034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/22/2018] [Accepted: 03/03/2018] [Indexed: 11/22/2022] Open
Abstract
Background Intraoperative Floppy Iris Syndrome (IFIS) is an important cause of surgical complications and iris defects in patients undergoing phacoemulsification that were treated with selective subtype α1A receptor antagonists for a long period of time. To date, no definitive preventive strategy has emerged, yet. The need of prophylaxis is dictated by the high prevalence of males affected by benign prostatic hyperplasia undergoing cataract surgery. Objective To identify the best prophylactic strategy in groups at risk of IFIS development by comparing two mydriatic treatments in course of phacoemulsification surgery. Methods 81 eyes of 81 patients in treatment with Tamsulosin were enrolled in the study. 43 eyes were treated with atropine sulfate 1% while 38 eyes received an injection of mydriatic solution containing epinephrine in the anterior chamber. All phacoemulsifications were videotaped in order to assess the occurrence of IFIS and the severity of the syndrome. Results The treatment group showed a statistically significant reduction (p = 0.0115) of floppy iris syndrome incidence, from 86.05% (37/43) of the atropine group to 60.53% (23/38). The analysis showed a reduction of IFIS mild form only, whereas the incidence of severe forms remained unchanged. Conclusions We believe that IFIS may arise through two different mechanisms: pharmacological antagonism and anatomical modifications. Patients suffering from mild forms of the disease showed a statistically significant reduction of IFIS incidence after intraoperative prophylaxis due to epinephrine's ability to displace Tamsulosin, resulting in the increase of iris tone when the disease is caused mainly by receptorial antagonism. On the contrary, prophylaxis does not deliver any valuable result in case of severe forms where the anatomical variations play a major role.
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Affiliation(s)
- Raffaele Nuzzi
- Eye Clinic Section and Specialization School in Ophthalmology, Institute of Ophthalmology, Department of Surgical Sciences, University of Turin, Turin, Italy.,Opthalmology Division, S. Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Paolo Arnoffi
- Opthalmology Division, S. Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Federico Tridico
- Eye Clinic Section and Specialization School in Ophthalmology, Institute of Ophthalmology, Department of Surgical Sciences, University of Turin, Turin, Italy.,Opthalmology Division, S. Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
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Abstract
This paper presents the review of historical aspects and the current state-of-the-art in various pupil dilatation methods to be used in cataract surgery. The surgical algorithm in managing small pupil cases should include topical and intraocular mydriatics, appropriately selected viscosurgical device and mechanical dilatation with instruments, iris hooks, and/or pupil expanders.
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Affiliation(s)
- Boris Malyugin
- S. Fyodorov Eye Microsurgery State Institution, Moscow, Russia
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Abstract
PURPOSE OF REVIEW To highlight the existing and emerging cataract surgery trends in patients with insufficient mydriasis. Discuss the latest pharmacological approaches for pre and intraoperative pupil dilatation. Present the variety of newest pupil expansion devices; critically review their advantages and possible limitations to be considered by the surgeon. RECENT FINDINGS The intracameral use of various mydriatic combinations augmenting the preoperative mydriatic instillations is currently gaining popularity in cataract surgery. Two main options are available: bolus injection of pharmacological agent or its constant irrigation during the phacoemulsification procedure. The former is aimed to expand the pupil, whereas the latter is mostly preventing the pupil from constriction. Introduction of femtosecond-assisted cataract surgery, apart from some benefits was followed by a variety of adverse effects including prostaglandin release into the aqueous humor causing pupil constriction. Preoperative administration of nonsteroidal anti-inflammatory drugs at least 1 day prior to surgery significantly decreases the chance of pupil constriction after laser energy is applied to the eye. However, pupil expansion devices may be needed in up to 10% of cases. Following the success of the Malyugin ring (MicroSurgical Technology Inc., Redmond, Washington, USA) several manufacturers introduced pupil expansion devices of various designs. They are differing with materials, pupillary margin fixation mechanisms, and easiness of manipulations during implantation and removal. SUMMARY Combination of proper use of pre and intraoperative pharmacological pupil dilatation protocols combined with pupil expander rings allow for well tolerated and effective cataract surgery in the vast majority of patients with insufficient mydriasis.
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Affiliation(s)
- Boris E Malyugin
- S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation
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Goyal S, Hardin J, Uwaydat SH, Ellabban AA, Warner DB, Sallam AB. Review and update of cataract surgery in the diabetic eye. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1351296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Sunali Goyal
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Cornea and External Diseases, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua Hardin
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sami H. Uwaydat
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Retina, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - David B. Warner
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Cornea and External Diseases, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ahmed B Sallam
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Retina, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
PURPOSE OF REVIEW Intraoperative floppy iris syndrome (IFIS) occurs in 2% of cataract surgeries and is associated with an increased risk of surgical complications. These complications can be avoided when high-risk patients are identified by preoperative screening and appropriate measures are used intraoperatively. The purpose of this article is to review emerging risk factors for IFIS and to summarize management strategies used in IFIS. RECENT FINDINGS Although α1-antagonists in general, and tamsulosin (Flomax, Jalyn) in particular, have long been associated with IFIS, recent studies have more firmly demonstrated the elevated risk of IFIS attributed to tamsulosin. This resulted in a revision of the American Society of Cataract and Refractive Surgery/American Academy of Ophthalmology guidelines on IFIS. Our understanding of additional medications and medical conditions involved in IFIS is also evolving, including an appreciation that women are also susceptible to IFIS. New modifications of techniques used in the intraoperative management of IFIS are also discussed. SUMMARY Preoperative screening should include both men and women. Current or prior use of α1-antagonists and antipsychotics should be documented, along with hypertension. Surgeons should be prepared to employ a range of perioperative interventions in a graded response to IFIS of different severities.
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Affiliation(s)
- Jennifer M Enright
- Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
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Gupta SK, Kumar A, Agarwal S, Agarwal S. Phacoemulsification without preoperative topical mydriatics: induction and sustainability of mydriasis with intracameral mydriatic solution. Indian J Ophthalmol 2015; 62:333-6. [PMID: 23571260 PMCID: PMC4061673 DOI: 10.4103/0301-4738.109521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Context: Intracameral mydriatic solution can eliminate the disadvantages of repeated eye drop instillation regimen and provide adequate mydriasis for phacoemulsification with added advantages. Aims: Evaluating the role of intracameral irrigating solution (0.5% lignocaine + 0.001% epinephrine) in initiating and maintaining the pupillary mydriasis during phacoemulsification. Secondary aims were to observe the effect of surgical time, nucleus density and ultrasound time on mydriasis during the procedure. Settings and Design: The study is a prospective interventional case series, conducted at tertiary care institution. Materials and Methods: Thirty patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Pupillary dilatation was achieved by intracameral irrigation of mydriatic solution alone. Pupillary diameter was measured serially during surgery and ultrasound time and total surgical time were noted. Statistical Analysis Used: Paired samples student–t test was done to compare means. Spearman correlation coefficient was used to study the effect of various parameters on mydriasis. Results: Thirty eyes completed the study. The pupil size increased from 2.1 mm (Range 2-3.5 mm SD ± 0.32) to 6.9 mm (Range 5-9 mm SD ± 1.02) in 30 seconds time after intracameral mydriatic solution delivery, and was 7.0 mm (Range 3.5 - 9 mm SD ± 0.20) at the end of surgery. Duration of surgery, grade of nucleus and ultrasound time had statistically insignificant effect on mydriasis. Conclusions: Intracameral solution containing 0.5% lignocaine and 0.001% epinephrine provides rapid mydriasis which is adequate for safe phacoemulsification and is unaffected by other parameters.
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Affiliation(s)
- Sanjiv K Gupta
- Department of Ophthalmology, Chatrapati Sahuji Maharaaj Medical University, Lucknow, Uttar Pradesh, India
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Prospective Masked Comparison of Intraoperative Floppy Iris Syndrome Severity with Tamsulosin versus Alfuzosin. Ophthalmology 2014; 121:829-34. [DOI: 10.1016/j.ophtha.2013.10.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 11/23/2022] Open
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Golembiewski JA, Babin SF. Safe Medication Compounding. J Perianesth Nurs 2013; 28:110-2. [DOI: 10.1016/j.jopan.2013.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 01/21/2013] [Indexed: 11/15/2022]
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Abstract
The intraoperative floppy iris syndrome (IFIS) describes an ophthalmologically relevant phenomenon which is observed after systemic intake of alpha blockers for treatment of benign prostate hyperplasia. This leads to an increase in intraoperative complications in cataract surgery characterized by a flaccid iris which billows in response to currents with a tendency to prolapse towards the area of surgery. This results in damage to the iris by the instruments used or posterior capsule rupture with loss of lens material. We describe the preoperative and intraoperative measures and techniques to deal with this challenging situation in order to minimize development of IFIS and reduce the complication rate.
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Intracameral Phenylephrine 1.5% for Prophylaxis against Intraoperative Floppy Iris Syndrome: Prospective, Randomized Fellow Eye Study. Ophthalmology 2012; 119:2053-8. [DOI: 10.1016/j.ophtha.2012.04.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 04/27/2012] [Accepted: 04/27/2012] [Indexed: 11/18/2022] Open
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Handzel DM, Briesen S, Rausch S, Kälble T. Cataract surgery in patients taking alpha-1 antagonists: know the risks, avoid the complications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:379-84. [PMID: 22690253 PMCID: PMC3371631 DOI: 10.3238/arztebl.2012.0379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 11/30/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND The growing use of alpha-1 receptor antagonists in the treatment of benign prostatic hyperplasia (BPH) has created a new problem in ophthalmic surgery, the so-called intraoperative floppy iris syndrome (IFIS). This consists of a billowing iris, insufficient pupillary dilation with progressive intraoperative miosis, and protrusion of iris tissue through the tunnel and side port incision that are made for access to the anterior chamber during surgery. IFIS presents particular difficulties in cataract surgery which is carried out through the pupil with manipulations in the immediate vicinity of the iris. The complications range from poor visibility of the operative field to iris damage with the surgical instruments and to rupture of the posterior capsule, with loss of lens material into the vitreous body. METHODS Selective literature review. RESULTS Alpha-blockers have a direct effect on the alpha-receptors of the iris but also induce ultrastructural changes in the iridial stroma, leading to IFIS. The most important factor in avoiding complications of IFIS seems to be the ophthalmic surgeon's knowledge that the patient is taking an alpha-1 receptor antagonist. CONCLUSION A thorough medical history and an optimized information flow among all physicians treating the patient-the urologist, the family physician, and the ophthalmic surgeon-are essential for safe cataract surgery.
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Ku TK, Naseri A, Han Y, Porco TC, Rutar T. Effect of Timing and Duration of Tamsulosin Exposure on Complications in Resident-Performed Phacoemulsification. Ophthalmic Surg Lasers Imaging Retina 2011; 42:416-22. [DOI: 10.3928/15428877-20110602-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 04/29/2011] [Indexed: 11/20/2022]
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Sallam A, El-Defrawy H, Ross A, Bashir SJ, Towler HMA. Review and update of intraoperative floppy iris syndrome. EXPERT REVIEW OF OPHTHALMOLOGY 2011. [DOI: 10.1586/eop.11.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pediatric intraoperative floppy iris syndrome associated with persistent pupillary membrane. J AAPOS 2011; 15:196-7. [PMID: 21463957 DOI: 10.1016/j.jaapos.2010.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 11/18/2010] [Accepted: 12/22/2010] [Indexed: 11/20/2022]
Abstract
Intraoperative floppy iris syndrome (IFIS) occurring during cataract surgery in adults has been widely reported in association with tamsulosin and other α-1(a) adrenergic antagonists; however, only one case of pediatric IFIS has been previously reported and was associated with congenital cataract. We report a case of a 1-month old girl with IFIS associated with bilateral persistent pupillary membranes without cataracts and the use of preoperative topical phenylephrine and pilocarpine for IFIS prophylaxis.
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Horvath K, Vultur F. Correlation between urological alpha1-AR antagonist medication and changed intraoperative iris behavior. Int Ophthalmol 2011; 31:99-104. [DOI: 10.1007/s10792-011-9423-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Accepted: 01/01/2011] [Indexed: 11/24/2022]
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Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. J Cataract Refract Surg 2010; 36:898-905. [DOI: 10.1016/j.jcrs.2009.12.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 12/15/2009] [Accepted: 12/15/2009] [Indexed: 10/19/2022]
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Storr-Paulsen A, Nørregaard JC, Børme KK, Larsen AB, Thulesen J. Intraoperative floppy iris syndrome (IFIS): a practical approach to medical and surgical considerations in cataract extractions. Acta Ophthalmol 2009; 87:704-8. [PMID: 19558575 DOI: 10.1111/j.1755-3768.2008.01442.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intraoperative floppy iris syndrome (IFIS) during cataract surgery is characterized by iris fluttering, iris prolapse towards the incisions, and a progressive pupillary constriction leading to high rates of complications. The syndrome has been reported following the treatment of benign prostatic hyperplasia with α-1(a) adrenergic receptor inhibitors, especially tamsulosin. The present paper describes the syndrome and discusses its pharmacological background. Several techniques to prevent and to deal with the syndrome are presented.
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Affiliation(s)
- Allan Storr-Paulsen
- Department of Ophthalmology, Frederiksberg University Hospital, Frederiksberg, Denmark.
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October consultation #5. J Cataract Refract Surg 2009. [DOI: 10.1016/j.jcrs.2009.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Keklikci U, Isen K, Unlu K, Celik Y, Karahan M. Incidence, clinical findings and management of intraoperative floppy iris syndrome associated with tamsulosin. Acta Ophthalmol 2009; 87:306-9. [PMID: 18384448 DOI: 10.1111/j.1755-3768.2008.01246.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the risk ratios and incidence of intraoperative floppy iris syndrome (IFIS) during cataract surgery in patients using tamsulosin, and to assess management strategies for IFIS. METHODS We performed a non-randomized, observational, prospective study, in which 594 eyes of 579 patients undergoing cataract surgery were enrolled. Surgeons were masked to the patients' drug history. Usage or non-usage of tamsulosin, duration of tamsulosin use, presence or absence of IFIS, management of IFIS and intraoperative complications were recorded in the patients' theatre notes. RESULTS Twelve of 15 (80%) IFIS patients were taking systemic tamsulosin. Twelve of 23 (52%) patients using tamsulosin showed features of IFIS. The odds ratios (ORs) and relative risk (RR) ratios show strong positive correlations between tamsulosin use and IFIS. The ORs and RR ratios and the 95% confidence intervals (CIs) are as follows: OR 206.5 (95% CI 50.9-836.5); RR 99.3 (95% CI 30.0-327.8). There were no statistically significant differences between patients with or without IFIS, who were using tamsulosin, in terms of age or duration of tamsulosin use (p > 0.05). Seven eyes (46.6%) with IFIS were successfully managed with epinephrine. Eight eyes (53.4%) with IFIS needed iris hooks. CONCLUSIONS Patients using tamsulosin appear to be at high risk of IFIS during cataract surgery. The occurrence of IFIS may not be affected by duration of tamsulosin use or age. Epinephrine may be effective in approximately 50% of eyes with IFIS. The iris hook procedure represents an effective management strategy in IFIS.
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Affiliation(s)
- Ugur Keklikci
- Department of Ophthalmology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey.
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Takmaz T, Can I. Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin. Eur J Ophthalmol 2008; 17:909-13. [PMID: 18050116 DOI: 10.1177/112067210701700607] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- T Takmaz
- Ataturk Training and Research Hospital, 2nd Ophthalmology Department, Ankara, Turkey.
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Chang DF, Osher RH, Wang L, Koch DD. Prospective Multicenter Evaluation of Cataract Surgery in Patients Taking Tamsulosin (Flomax). Ophthalmology 2007; 114:957-64. [PMID: 17467530 DOI: 10.1016/j.ophtha.2007.01.011] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 01/10/2007] [Accepted: 01/10/2007] [Indexed: 11/28/2022] Open
Abstract
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.
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