What urologists know about intraoperative floppy-iris syndrome

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.

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.

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.

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.