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

Prevalence and prediction of intraoperative floppy iris syndrome in patients with pseudoexfoliation syndrome

OBJECTIVE

To investigate the incidence of intraoperative floppy iris syndrome (IFIS) in patients with pseudoexfoliation syndrome (PXF) and analyze preoperative ocular predicting factors.

DESIGN

A retrospective case-control study METHODS: The study included 224 eyes with PXF and 287 control eyes without PXF. One eye per patient, who underwent cataract surgery at the Wolfson Medical Center between January 2020 to December 2021, was included. Medical records of the patients were reviewed. Data collected included demographic characteristics, medical history, preoperative comprehensive ophthalmic examination, biometry, surgical procedure details, and IFIS occurrence. The association of IFIS with preoperative ocular parameters was analyzed through both univariant and multivariant analyses.

RESULTS

Patients with PXF were older and had a higher prevalence of glaucoma (77.6 ± 6.4 years vs 74.2±7.6 years; p < 0.001, and 20.1 % vs 9.8 %, p < 0.001, respectively). Prevalence of α-blockers treatment was similar in both groups. IFIS rate among the PXF group was 12.5% (n = 28) compared to 7.3% (n = 21) in the control group (p < 0.05). When omitting patients exposed to α-blockers, the PXF group exhibited a significantly higher IFIS rate (9.9% vs 4.8%; p < 0.05). Pupil dilation diameter was significantly lower among PXF patients (5.8 ± 1.1 mm vs 6.9 ± 0.99 mm; p < 0.001). Biometric evaluation revealed significant differences in anterior segment depth (ACD) and lens thickness (LT). Multivariate analysis indicated that PXF and decreased mydriatic pupil size remained significant predictors of IFIS.

CONCLUSION

This study establishes an association between PXF and an increased risk of IFIS during cataract surgery, independent of α-blockers treatment.

[Intraoperative floppy iris syndrom (IFIS) associated with tamsulosin]

BACKGROUND

Tamsulosin is one of the most commonly prescribed alpha-1A antagonists for the treatment of benign prostatic syndrome (BPS). Patients treated with tamsulosin often develop intraoperative floppy iris syndrome (IFIS) during cataract surgery. This leads to increasing miosis and an undulating iris, which increases the risk of complications significantly and can cause permanent damage.

AIM OF THE WORK

The aim is to raise awareness for the effects of tamsulosin intake before cataract surgery.

MATERIAL AND METHODS

We conducted a critical review of publications on the association of IFIS in cataract surgery with alpha-receptor blockers.

RESULTS AND DISCUSSION

Tamsulosin has a risk of complications of up to 80 %, whereas doxazosin and alfuzosin only have a 15-20 % chance of complications. Tamsulosin therefore represents a significant risk factor for permanent secondary damage after cataract surgery. Even after discontinuing tamsulosin, IFIS was still observed after up to 3 years. Nevertheless, pausing of tamsulosin intake is recommended. An alternative preparation should therefore be preferred in patients who have not yet had cataract surgery. If patients are already pseudophakic, tamsulosin can be given without concern.

Bilateral posterior capsule rupture and anterior vitreous prolapse from vigorous eye rubbing

Purpose

We present the case of a 71-year-old male who developed decreased visual acuity eleven years after uncomplicated bilateral cataract extraction and in-the-bag IOL implantation following recent bouts of vigorous eye rubbing.

Observations

On examination, the posterior capsules were ruptured centrally in both eyes, and there was anterior vitreous prolapse bilaterally. While both IOLs remained in the visual axis, there was mild bilateral decentration and resultant decreased vision.

Conclusion and importance

To the authors’ knowledge, this is the first reported case of bilateral simultaneous posterior capsule rupture with anterior vitreous prolapse due to eye rubbing. Contrasting to previous case reports, this scenario demonstrates that severe eye rubbing can have variable severity and complications. Frequent and vigorous eye rubbing can be a precipitating cause of late postoperative posterior capsule rupture and should be avoided in pseudophakic patients, especially those with older IOL models.

Dealing with floppy iris syndrome

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.

Preoperative atropine and non-steroidal anti-inflammatory drugs for the prevention of intraoperative floppy iris syndrome

PURPOSE

To examine the efficacy of preoperative administration of topical atropine 1% and non-steroidal anti-inflammatory drugs (NSAIDs) for prevention of intraoperative floppy iris syndrome (IFIS).

METHODS

In this retrospective cohort study, patients who underwent cataract surgery by phacoemulsification between July 2019 and February 2020 in two hospitals were included. Both hospitals are located in central Israel, have similar patient demographics and employ similar surgical techniques. They, however, differ in policy of IFIS prevention. In Meir Medical Center no preventive medications are given pre-operatively, while in Shamir Medical Center patients at-risk for IFIS receive topical atropine 1% once daily and non-steroidal anti-inflammatory drugs (NSAIDs) thrice daily for 3 days preoperatively.

RESULTS

Overall, 207 eyes of 207 patients with history of alpha-antagonist use were included. Mean age was 74.9 ± 7.8 years and 82.1% (n = 170) were male. Among patients from the pretreating center 86.8% (n = 92/106) were pre-treated with either NSAIDs or atropine preoperatively, while in the non-pretreating center no treatment was prescribed (n = 0/101). IFIS rate among the non-pretreating center was 29.7% (n = 30/101) compared to 15.1% (n = 16/106) in the pretreating center (p = 0.012). When strictly comparing treated to untreated patients, the treated group had an IFIS rate of 12.0% compared to 30.4% among untreated (p = 0.001). Adjusted for age and gender results remain consistent (odds ratio 0.329 for treated patients, 95% confidence interval: 0.150-0.720; p = 0.005).

CONCLUSIONS

IFIS rates were significantly lower in the pretreating center compared to the non-pretreating center. When comparing strictly treated to untreated patients, differences were even more pronounced.

Why Use Ultrashort Pulses in Ophthalmology and Which Factors Affect Cut Quality

The power density of femtosecond lasers and exposure time to the tissue are crucial for a successful procedure in terms of safety and precision. The reduction of the pulse duration allows reducing the quantity of the energy to be delivered to the tissue for disruption with strongly diminished mechanical and thermal collateral damage. The cutting effect of ultra-short pulses is very precise, minimally traumatic, safe, and predictable. Future developments will lead to further energy reductions to achieve optical breakdowns. However, the pulse length cannot be shortened arbitrarily because below 100 fs nonlinear effects can change the process in an unfavorable way. Compared to manual-conventional cataract surgery, femtosecond laser-assisted cataract surgery (FLACS) shows many advantages in clinical application, especially with regard to precision and tissue protection. The femtosecond laser has become particularly important and has made the overall procedure safer when we deal with complex cataract cases such as subluxated lenses. We provide an overview of the evolution of femtosecond laser technology for use in refractive and cataract surgeries. This article describes the advantages of available laser platforms with ultrashort pulses and mainly focuses on the technical and physical backgrounds of ophthalmic surgery technologies.

Intraoperative Floppy Iris Syndrome Induced by Tamsulosin: The Risk and Preventive Strategies

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.

Management of common iatrogenic iris defects induced by cataract surgery

The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This article discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques.

A narrative review of intraoperative floppy iris syndrome: an update 2020

Intraoperative floppy iris syndrome (IFIS) is characterized by intraoperative floppiness or billowing of the iris, progressive miosis, and iris prolapse through the surgical wounds. It was originally reported about fifteen years ago, which was later identified to be closely associated with tamsulosin, the most commonly used α1 adrenoceptor antagonist for benign prostatic hyperplasia (BPH). A variety of risk factors, including age, gender, hypertension, axial length of the eye, 5α-reductase inhibitors, other α adrenoceptor antagonist and neuromodulators, have been connected with IFIS. If IFIS occurs during phacoemulsification surgery, complications such as corneal endothelial loss, iris trauma, posterior capsule rupture (PCR), high intraocular pressure and vitreous loss are significantly increased. Therefore, preoperative evaluation of high-risk patients and appropriate intraoperative intervention is crucial to avoid severe complications. This review summarizes the pathogenesis and clinical features of classic IFIS, and provides some clinical pearls to ophthalmologists that may help identify, prevent or reduce IFIS associated complications. Additionally, from the perspective of clinical occurrence of IFIS, there are some recommendations for urologists as well. In conclusion, both ophthalmologists and urologists should be aware of this special clinical situation and communicate with each other about their own fields. A multidisciplinary interaction is of importance to simplify potentially complicated clinical issues.

Modified Corneal Incisions for Cataract Surgery in Patients Treated with Tamsulosin: A Prospective Study

PURPOSE

To evaluate modified anterior elongated corneal incisions as a simple technique to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS), in patients taking tamsulosin (a selective α_1a-adrenergic receptor antagonist).

METHODS

This prospective case series was conducted at Meir Medical Center, a tertiary care facility in Israel. Included were 45 eyes of 39 male patients taking tamsulosin, and thus prone to IFIS. Patients underwent phacoemulsification cataract surgery with anterior elongated corneal incisions. The primary outcomes were the incidence and severity of IFIS, the complication rate and the need for additional IFIS management techniques. The secondary outcome was to quantify the surgically induced astigmatism, using Alpin's vector analysis. The tamsulosin treatment period and pupil diameter during five stages of the surgery were also noted.

RESULTS

The overall rate of IFIS was 33.33% (n = 15). The IFIS severity was rated as mild in 22.22% and moderate in 11.11% of the study eyes. No IFIS was noted in 66.67% of the eyes. There were no cases of severe IFIS, and no need for other IFIS management strategies. The complications rate was 2.22% (n = 1). Patients who developed IFIS had a significantly smaller pupil at the beginning of surgery (p < 0.05). There was no significant difference in tamsulosin treatment period between patients with and without IFIS (p = 0.19). The centroid - the mean SIA vector was 0.51 D @ 18° ±1.5 D (SD).

CONCLUSIONS

In tamsulosin treated patients, using modified corneal incisions may be feasible in order to reduce the incidence and severity of IFIS during cataract surgery. Future randomized studies are warranted.

Clinical risk factors associated with intraoperative floppy iris syndrome: a prospective study

PURPOSE

To evaluate the incidence of and factors associated with intraoperative floppy iris syndrome (IFIS) in patients undergoing cataract phacoemulsification.

METHODS

In total, 319 eyes of 319 patients who underwent phacoemulsification with implantation of an intraocular lens (IOL) into the posterior chamber were included in this study. Direct injection of epinephrine into the anterior chamber was performed in all cases. The following patient information was collected: gender, age, axial length of the eye, presence of pseudoexfoliation syndrome, glaucoma, diabetes mellitus, hypertension, current use of medications including alpha1 adrenergic receptor antagonists (alpha1-ARAs), finasteride, and benzodiazepines, duration of intake of alpha1-ARAs and finasteride, and duration of the surgery. Patients were classified as IFIS or non-IFIS after the surgery. Univariate and multivariate logistic regression analyses were performed.

RESULTS

The overall incidence of IFIS was 9.09% (29/319 eyes). The multivariate analysis revealed that tamsulosin use (P = 0.004), finasteride use (P = 0.014), and increasing age (P = 0.006) were significantly associated with IFIS. Male gender and benzodiazepine use were significantly associated with IFIS in the univariate analysis, but not in the multivariate analysis. The non-selective alpha1-ARA doxazosin was not found to be associated with IFIS.

CONCLUSIONS

The findings suggest that finasteride use and aging are risk factors for IFIS and confirm the association of tamsulosin use with IFIS. Further, doxazosin appears to be a relatively safe drug with respect to the occurrence of IFIS.

Ten years of intraoperative floppy iris syndrome in the era of α-blockers

Introduction

The use of alpha-1 receptor antagonists in the treatment of benign prostatic hyperplasia (BPH) has created a 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.

Material and methods

A comprehensive literature review was performed using MEDLINE with MeSH terms and keywords 'benign prostatic hyperplasia', 'intraoperative floppy iris syndrome', 'adrenergic alpha-antagonist' and 'cataract surgery'. In addition, reference lists from identified publications were reviewed to identify reports and studies of interest from 2001 to 2017.

Results

The A total of 95% of experienced ophthalmologic surgeons reported that systematic treatment with tamsulosin represents a challenging surgical condition increasing the risk of complications. Alpha-blockers are commonly prescribed, with 1,079,505 packages of tamsulosin prescribed each month in 2014 in Austria. Dose modification may be one way to reduce the risk of IFIS. A lower incidence of IFIS was reported in patients on tamsulosin in Japan, but the recommended dosage was lower than that used in Europe and the US (0.2 mg vs. 0.4 mg).

Conclusions

We showed that not all patients taking tamsulosin experience IFIS. Moreover, larger investigations with a prospective design are needed, including studies to monitor the pre- and post-therapeutic ophthalmologic changes under tamsulosin, as well as urodynamic improvements resulting from this therapy.

Floppy iris syndrome and cataract surgery

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.

Intraoperative floppy iris syndrome in Indian population: a prospective study on incidence, risk factors, and impact on operative performance

PURPOSE

The purpose of this study was to evaluate the incidence, risk factors, and impact of intraoperative floppy iris syndrome (IFIS) on surgical performance.

MATERIALS AND METHODS

Consecutive cataract surgeries from October 2010 to Feb 2011 (1003 eyes, 980 patients; 568 males, 412 females) were analyzed prospectively. Operating surgeon, masked about medication history, noted the intraoperative details. Cases were identified as IFIS or non-IFIS. Multivariate analysis was performed to find risk factors for IFIS.

RESULTS

Prevalence of tamsulosin use among men undergoing cataract surgery was 7.0% (41) with incidence of IFIS 4.78% (48). On multivariate analysis, hypertension (OR: 3.2, 95% confidence interval, 95% CI: 1.39-6.57; P = 0.005), use of tamsulosin (OR: 133.32, 95% CI: 50.43-352.48; P < 0.0001), or alfuzosin (OR: 9.36, 95% CI: 2.34-37.50; P = 0.002) were the factors associated with IFIS. Among men taking tamsulosin (n = 41) and alfuzosin (n = 28), 68.3% and 16.6% developed IFIS, respectively. In subgroup analysis of men on tamsulosin, no factor added to the risk posed by tamsulosin. Seventeen of 944 eyes not exposed to any drug had IFIS (0.018%). On subgroup analysis, only risk factor for IFIS was hypertension (OR: 4.67, 95% CI: 1.63-13.35; P = 0.002). Of 48 IFIS eyes, the surgeon observed increased difficulty in 57.1% (21) and additional measures were required in 9 eyes. Mean operative time was increased in IFIS eyes (11.68 ± 3.46 vs. 10.01 ± 0.22 min; P = 0.001). Surgical outcome was good in all cases.

CONCLUSION

The prevalence of tamsulosin intake and IFIS incidence is higher in India. Current tamsulosin/alfuzosin use and hypertension are important risk factors. IFIS makes the surgery more difficult, significantly prolongs the operative time, and predisposes for other intraoperative complications. However, with appropriate management, final operative outcome is not affected.

Intraoperative floppy iris syndrome and its association with various concurrent medications, bulbus length, patient age and gender

PURPOSE

To evaluate the association between intraoperative floppy iris syndrome (IFIS) and concurrent medications containing selective alpha1A receptor antagonists as well as nonselective alpha1-adrenergic receptor antagonists, bulbus length, patient age and gender.

METHODS

We performed a prospective data acquisition of IFIS occurrence and grading, and retrospective evaluation of concurrent medications, bulbus length, patient age and gender of all patients undergoing cataract surgery over a 6-month period.

RESULTS

IFIS was observed in 119 of 947 cases (12.6 %). 31 of those 119 patients (26.1 %) had a concurrent medication with a drug that is associated with a higher risk of causing IFIS. Tamsulosin was the drug most commonly associated with IFIS (n = 11), followed by a combination of drugs (n = 7), doxazosin (n = 4), quetiapine (n = 4), finasterid (n = 2), prothipendyl (n = 2), and mianserin (n = 1). Bulbus length and age did not show any significant association with occurrence or grade of IFIS. Gender distribution among IFIS cases was 57.1 % males (n = 68) and 42.9 % (n = 51) females.

CONCLUSIONS

The occurrence of IFIS has to be expected with a variety of concurrent medications. The number of IFIS cases and the percentage of females in this series are higher compared to previous reports. The observations might be due to a rising awareness of surgeons or to an increasing number of causative medications on the market.

Assessment of Urologists' Knowledge of Intraoperative Floppy Iris Syndrome

OBJECTIVES

To assess urologists' awareness of intraoperative floppy iris syndrome.

MATERIALS AND METHODS

A questionnaire composed of 21 questions was emailed to all of the Urology residency programs in the U.S. and all members of the Western section of the American Urological Association. Responses were collected and analyzed using statistical software.

RESULTS

A total of 175 responses were collected from residents, fellows, and attending physicians from a wide range of geographic locations, subspecialties, and practice settings. Thirty percent of the urologists would routinely discuss intraoperative floppy iris syndrome with patients prior to start of benign prostate hyperplasia treatment. Twenty-one percent of the respondents never asked patients about ophthalmologic conditions prior to benign prostate hyperplasia treatment. If patients had concurrent visual complaints, only 37% of the respondents would routinely encourage patients to speak to an ophthalmologist and only 13% would routinely refer patients to an ophthalmologist. A comparison among the subgroups based on training status and practice settings further showed that a significantly higher percentage of residents would not ask about visual complaints or refer patients with visual complaints to an ophthalmologist compared with fellows and attending physicians (P <.01); however, there was no significant difference between urologists in academic and nonacademic settings (P >.05).

CONCLUSION

Despite continuing effort to educate physicians about intraoperative floppy iris syndrome, there still exists a knowledge gap that may compromise patient care and further education is needed.

Risk factors for intraoperative floppy iris syndrome: a prospective study

PurposeTo evaluate risk factors for intraoperative floppy iris syndrome (IFIS) in patients undergoing phacoemulsification.MethodsParticipants in the study were 1274 consecutive patients, who underwent routine phacoemulsification cataract surgery. The following data were recorded and evaluated as possible risk factors: ophthalmological conditions, axial length of the eye, sociodemographic features, clinical data (hypertension and diabetes mellitus), medications being taken at the time of surgery, and duration of their intake. Cases were characterized intraoperatively as IFIS and non-IFIS. Univariate and multivariate logistic regression analysis were performed.ResultsIFIS was observed in 63/1274 eyes (4.9%, 95% CI: 3.9-6.7%). Current use of tamsulosin, alfuzosin, terazosin, benzodiazepines, quetiapine, and finasteride, as well as hypertension, were all independently associated with IFIS. Significant associations were noted for male sex, rivastigmine, and short axial length, which did not reach significance at the multivariate analysis. Duration of α-blockers intake was not found to be associated with IFIS.ConclusionApart from the well-established associations with α-blockers, this prospective study points to benzodiazepines, quetiapine, finasteride, and hypertension as potential risk factors for IFIS. Short axial length and rivastigmine were significantly associated with IFIS only at the univariate analysis.

Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran

Purpose:

To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.

Methods:

First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.

Results:

The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.

Conclusion:

Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.

[Pharmacotherapy of urinary incontinence in the elderly]

The prevalence and the incidence of Urinary Incontinence is growing. Women suffer predominantly from stress and mixed urinary incontinence and men from urge incontinence. In elderly people, the pathophysiological and the physiological change in the lower urinary tract system must be considered as well as an underlying multimorbidity. Stress urinary incontinence is among others caused by an insufficient urethral closure mechanism and urge incontinence is followed by unhibited detrusor contractions. Medical treatment is beside other important conservative options only one part of the treatment strategy in incontinence. Duloxetine, a serotonine-norepinephrine reuptake inhibitore can increase activity of the external urethral sphincter and is able to reduce incontinence episodes in up to 64 %. Antagonists of muscarinic receptors can reduce urgency, frequency and urge incontinence as well as increase bladder capacity significantly. In Germany, darifenacin, fesoterodin, oxybutynin, propiverine, solifenacin, tolterodine and trospium chloride are available to treat urge incontinence. The efficacy of these agents are almost comparable in the elderly with the exception of oxybutynin IR. However, tolerability is different and not well studied in the elderly population with the exception of fesoterodin. Side effects, especially dry mouth, dizziness and constipation often limit their use. None of the agents show ideal efficacy or tolerability in all patients. Last summer therefore a β3-agonist mirabegron was also introduced in Germany but was withdrawn.

Modified corneal incisions in intraoperative floppy iris syndrome (IFIS)-prone patients

BACKGROUND

We aimed to report a simple technique that involves modified anterior (to the limbus) elongated corneal incisions in order to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS) and related complications.

METHODS

This was a retrospective study of phacoemulsification cataract surgeries performed by a single surgeon on patients receiving tamsulosin or alfuzosin between 1 January 2009 and 31 July 2012 at Meir Medical Center, Kfar-Sava, Israel. We recorded preoperative gender, age, α-antagonist medication, coexisting pseudoexfoliation (PXF), and intraoperative use of ophthalmic viscosurgical devices (OVDs), pupil size, complications, IFIS grading and the need for additional operative strategies to manage IFIS. Elongated corneal incisions were performed approximately 1 mm anterior to the limbus.

RESULTS

Ninety-three eyes of 81 men were included. Mean age was 76.5 years (range 55 to 96 years). Forty-seven eyes (40 patients) had documented use of alfuzosin and 45 eyes (40 patients) of tamsulosin. One patient received both. The overall rate of IFIS was 22.6 % (n = 21). Eyes of patients who were treated with alfuzosin had a milder grading (p < 0.001) and an overall lower percentage of IFIS compared to tamsulosin (4.26 % versus 42.22 % respectively, p < 0.001). No additional strategies were used to manage IFIS during surgery. No intraoperative complications occurred.

CONCLUSION

Anterior elongated incisions are simple and efficient in preventing IFIS, exempting the surgeon from the use of additional expensive devices or materials in most cases. They do not limit the surgeon to one strategy, and therefore, if necessary, another may be applied at any given time.

Lower urinary tract symptoms in men

Benign prostatic hyperplasia (BPH) is a highly prevalent and costly condition that affects older men worldwide. Many affected men develop lower urinary tract symptoms, which can have a negative impact on their quality of life. In the past, transurethral resection of the prostate (TURP) was the mainstay of treatment. However, several efficacious drug treatments have been developed, which have transformed BPH from an acute surgical entity to a chronic medical condition. Specifically, multiple clinical trials have shown that α adrenoceptor antagonists can significantly ameliorate lower urinary tract symptoms. Moreover, 5α reductase inhibitors, alone or combined with an α adrenoceptor antagonist, can reverse the natural course of BPH, reducing the risk of urinary retention and the need for surgical intervention. Newer medical regimens including the use of antimuscarinic agents or phosphodiesterase type 5 inhibitors, have shown promise in men with predominantly storage symptoms and concomitant erectile dysfunction, respectively. For men who do not adequately respond to conservative measures or pharmacotherapy, minimally invasive surgical techniques (such as transurethral needle ablation, microwave thermotherapy, and prostatic urethral lift) may be of benefit, although they lack the durability of TURP. A variety of laser procedures have also been introduced, whose improved hemostatic properties abrogate many of the complications associated with traditional surgery.

The effects of tamsulosin and alfuzosin on iris morphology: an ultrasound biomicroscopic comparison

CONTEXT

It is well known that Alpha-1 adrenergic receptor antagonists affect the receptors in the prostate and also iris dilator muscle, leading to loss of iris muscle tone.

OBJECTIVE

To compare morphological alterations of iris secondary to tamsulosin and alfuzosin use.

PARTICIPANTS

Patients included in the study were grouped as follows: 16 patients treated with tamsulosin (Group 1), 14 patients treated with alfuzosin (Group 2) and 18 untreated controls (Group 3).

MATERIALS AND METHODS

All patients underwent ultrasound biomicroscopic and pupillometric examination. Iris thickness was measured at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and sphincter muscle region (SMR; Standardized at 0.75 mm from the pupillary margin). DMR/SMR was also calculated for each patient. Differences among groups were analysed. Main outcome measures were DMR, SMR, DMR/SMR and pupillary diameter.

RESULTS

Mean duration of treatments were 2.4 ± 0.96 years (1-4) and 2.3 ± 1.01 years (1-4) in Groups 1 and 2. Pupillary diameters were reduced in Groups 1-2 compared to Group 3 (p < 0.001, p < 0.001). The SMR was similar in Groups 1 and 2 (p: 0.114). These values were not significantly different from that of Group 3 (p: 0.196, p: 0.209). However, thickness in the DMR in Groups 1-2 were significantly lower than that of controls (Group 3) whereas there was no significant difference between Groups 1 and 2 (p: 0.041, p: 0.039 and 0.986, respectively). Mean DMR/SMR ratios were significantly lower in Groups 1-2 than that of Group 3 (p: 0.040 and p: 0.040, respectively).

CONCLUSIONS

In patients using these medications, the iris seems to be thinner at the dilator muscle region, but preserving the sphincter muscle region.

Femtosecond laser cataract surgery: challenging cases

PURPOSE OF REVIEW

Emerging data in the peer-reviewed literature indicate that femtosecond laser-assisted cataract surgery (LCS) is a well tolerated and effective alternative to conventional phacoemulsification. Initial reports have largely been based on findings from an optimal patient selection. As confidence with the technology has grown, clinical indications have expanded and the benefit of LCS in high-risk patients with complex cataracts is increasingly being considered.

RECENT FINDINGS

We discuss challenging cataract surgery cases, citing the currently available literature alongside experience from over 3000 completed LCS cases at our centre.

SUMMARY

Current experience is limited. However, LCS platforms are continuously evolving and improving. The results collected to date would suggest that the precision and safety offered by LCS may improve outcomes in these challenging cases.

Comparing the efficacy of mydriatic cocktail-soaked sponge and conventional pupil dilation in patients using tamsulosin - a randomized controlled trial

BACKGROUND

A strong association exists between the use of tamsulosin and the occurance of intraoperative floppy iris syndrome. Several methods were advocated to overcome the progressive intraopertive miosis.Our purpose was to investigate the effect of a mydriatic-cocktail soaked cellulose sponge on perioperative pupil diameter in tamsulosin-treated patients undergoing elective cataract surgery.

METHODS

Patients using tamsulosin were dilated either with mydriatic-cocktail soaked sponge (group 1) or with conventional eyedrop regimen (group 2). Control patients not taking any α1 adrenergic receptor inhibtors were also dilated with mydriatic sponge (group 3).In all groups oxybuprocain 0.4%, cocain 4%, tropicamide 1%, phenylephrine 10%, diclophenac 0.1% along with chloramphenicol 0.5% were used preoperatively.Pupil diameter (mm) was measured preoperatively, after nucleus delivery, and before IOL implantation. Adverse effects associated with the use of sponge, minor and major intraoperative complications, the use of iris retractors and operation time were recorded.Differences in general between groups were analyzed with a one way analysis of variance (ANOVA); differences between groups in proportions were assessed by Fisher's exact test.

RESULTS

Mean pupil diameter (mm) was preopertively: 7.52 ± 1.21, 7.30 ± 1.55 and 7.99 ± 0.96 (ANOVA: p = 0.079); after nucleus delivery: 6 ± 1.20, 6.29 ± 1.12 and 6.52 ± 0.81 (ANOVA: p = 0.123); before IOL implantation: 5.46 ± 1.06, 5.83 ± 1.09 and 6.17 ± 0.89 (ANOVA: p = 0.0291).No adverse effect related to sponge use was detected. Frequency of minor complications, and iris hook use was similar in the two tamsulosin treated group. Operation time did not differ significantly in the three groups.

CONCLUSION

We have found that using a mydriatic cocktail-soaked wick - an alternative way to achieve intraoperative mydriasis for cataract surgery - was as effective and safe as the conventional repeated eyedrops regiment for tamsulosin treated patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37834752.

Intraoperative floppy-iris syndrome

OBJECTIVE

Intraoperative-floppy iris syndrome (IFIS) has been recently described. It has been demonstrated that this new syndrome complicates cataract surgery. In this paper we have reviewed the syndrome, and offer practical information specially related to the origin and management of this syndrome and we offer practical information.

MATERIAL AND METHODS

A review of the related medical literature using PubMed and Cochrane databases. Combining the search terms tamsulosin, cataract, IFIS and intraoperative floppy iris syndrome, more than 200 articles were found. Eighty-two of them were obtained and analysed. In the remaining only the abstract could be studied.

RESULTS

The aetiological association between IFIS and tamsulosin (and to a lesser degree between IFIS and other alpha-antagonists) is well established. Other aetiological associations are doubtful. Most of the literature is centred on cataract surgery. However, a similar syndrome has been described during trabeculectomy. A possible association between these drugs and choroidal detachments has also been described. Undoubtedly tamsulosin treatment makes cataract surgery more difficult and increases the probability of intraoperative complications. Protocols to manage the syndrome have not yet been developed. Intracameral injection of alpha-adrenergic agonists seems to be useful. However there is no evidence of the usefulness of discontinuing the drug or using preoperative mydriatics.

CONCLUSION

The aetiological and clinic features of the syndrome are well established. More studies are needed to provide scientific evidence on the most appropriate way to cope with this syndrome.

[Managing complications in intraoperative floppy iris syndrome]

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.

Practice patterns and opinions in the management of recurrent or chronic herpes zoster ophthalmicus

PURPOSE

The objective of this study was to determine current practices and opinions among cornea specialists for treating and preventing recurrences of herpes zoster ophthalmicus (HZO).

METHODS

In November 2010, a survey of 15 questions was distributed to The Cornea Society listserv. Questions identified respondents' treatment practices for recurrent HZO and opinions regarding prolonged antiviral prophylaxis and zoster vaccine.

RESULTS

Of 100 respondents, the majority were cornea specialists (83 of 98, 85%). Eighty-seven percent (84 of 97) reported treating recurrent or chronic cases of HZO in the last year. The most common choice of treatment in the posed recurrent HZO clinical scenario was a combination of oral antiviral and topical corticosteroid (63 of 100, 63%), although significant variability existed in the duration of oral antiviral administration. Fifty-four respondents (56%) believed that prolonged acyclovir prophylaxis could reduce recurrent signs of HZO; 28% (27 of 98) believed that recurrences of HZO could be reduced after the period of acyclovir administration. For patients with a history of HZO, most respondents reported not recommending the adult zoster vaccine (63 of 98, 64%), but 46% (43 of 94) believed that the vaccine could reduce recurrent signs or did not know.

CONCLUSIONS

Many cornea specialists are managing recurrent or chronic cases of HZO, but there is variability in the use of topical corticosteroids and antivirals. Additionally, no consensus exists on the efficacy of prolonged antiviral therapy or the adult zoster vaccine to reduce chronic or recurrent disease. These results demonstrate the need for further systematic study of treatment and prophylaxis for recurrent and chronic HZO.

Management of intraoperative iris prolapse: stepwise practical approach

Iris prolapse is not an uncommon occurrence during cataract surgery. It usually occurs through the main incision during hydrodissection and is commonly associated with floppy-iris syndrome; however, it can manifest in cases with no known predisposition and can occur at any stage during surgery. The mechanism is explained by the Bernoulli principle and its effect on iris position during the movement of fluid within the eye. Predisposing factors are iris configuration, anterior chamber depth, and position and architecture of the corneal tunnel. Strategies for prevention and management include the use of pharmacological agents, ophthalmic viscosurgical devices, and iris retractors. These strategies can be augmented by alteration and adaptation of the surgeon's technique.

Cataract surgery in patients taking alpha-1 antagonists: know the risks, avoid the complications

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.

The effect of alpha antagonists on pupil dynamics: implications for the diagnosis of intraoperative floppy iris syndrome

PURPOSE

To assess pupil dynamics quantitatively in relation to the use of α1-adrenoceptor antagonists, which contribute to the features of intraoperative floppy iris syndrome, using a new, hand-held, digital pupillometer.

DESIGN

Prospective case-control study.

METHODS

We studied 15 and 25 patients administered tamsulosin and alfuzosin, respectively, as well as 25 control patients. Resting pupil diameter and subsequent contraction, latency, constriction velocity, and dilation velocity were recorded using an electronic pupillometer. All pupil measurements were performed before and after pharmacologic dilation.

RESULTS

In predilation pupillary measurements, we detected a significant decrease in maximum pupillary diameter by 0.50±0.19 mm (P=.011) and in the mean percentage of diameter reduction after stimulation (5.23±2.42%, P=.035) in the tamsulosin group. Alfuzosin also induced a significant decrease in maximum pupillary diameter (0.49±0.17 mm, P=.005). Constriction velocity was significantly reduced by 0.70±0.20 m/s (P=.001) in the tamsulosin group and by 0.54±0.18 m/s (P=.004) in the alfuzosin group. In terms of postdilation measurements, maximum and minimum pupil diameters were reduced significantly only in the tamsulosin group (by 1.09±0.31 mm [P=.001] and by 0.89±0.36 mm [P=.016], respectively).

CONCLUSIONS

We describe a reliable, accurate, and rapid method to acquire quantitative pupil measurements and identify the tendency for intraoperative floppy iris syndrome before cataract surgery after the use of alfuzosin and tamsulosin. This investigation also analyzed the similarities and differences induced by the 2 drugs in predilation and postdilation pupil dynamics, demonstrating that tamsulosin is more potent than alfuzosin in inducing intraoperative floppy iris syndrome.

Complications of cataract surgery in patients with BPH treated with alpha 1A-blockers

The prevalence of benign prostate hyperplasia (BPH) and cataract increases with age. Both diseases may develop concomitantly and may affect almost 50% of elderly men as comorbidities. Cataract is treated surgically and it has been reported that there may be an association between use of alpha-blockers for BPH, particularly alpha1A-adrenergic receptor selective drugs, and complications of cataract surgery known as Intraoperative Floppy Iris Syndrome (IFIS). The article reviews literature published on this topic and provides recommendations on how to reduce incidence of iatrogenic IFIS or its severity and outcomes in patients with BPH.

Annual drug update: 2010 in review

In 2010, the FDA approved several new drugs and new indications for use in primary care. From new therapies for adults with rheumatoid arthritis to a combination drug for benign prostatic hyperplasia, NPs need to be aware of the latest medications now available.