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What is the best method for managing IFIS?

Intraoperative floppy iris syndrome (IFIS) occurs in a significant number of patients with tamsulosin associated cataract extractions.1,2 It is important that possible sequelae are anticipated and surgery is carefully planned, so that visual outcome is not adversely affected.1,2 Based on available data, it is recommend that patients who are taking or have taken tamsulosin should be operated on by senior cataract surgeons who can employ compensatory measures to manage IFIS. Stopping tamsulosin before the surgery does not appear to prevent IFIS and is therefore not advised.2 There are no published trials to inform the most appropriate method for managing IFIS. Surgeon’s choice is mainly based on personal experience and case difficulty.3 For tamsulosin patients with preoperative dilated pupil diameter of 6 mm or more, I do not routinely employ any prophylactic measures, however, I prepare intracameral phenylephrine (1:360) and use it at the earliest signs of IFIS, if it is encountered.4 For eyes with small pupil at the outset, intracameral phenylephrine is unlikely to enlarge the pupil significantly4 and therefore, I routinely use a mechanical modality in these cases to expand the pupil and control the iris and my choice is mainly between iris hooks or a 6.25mm Malyugin ring. In my hands, neither the use of Healon5 nor preoperative atropine drops has been reliable for the management of IFIS. Despite the use of low fluidic parameters, it is difficult to maintain Healon5 in a sufficient volume in the anterior chamber to control the iris throughout surgery even with repeat injections.2 As demonstrated in the tamsulosin prospective trial,2 preoperative atropine drops are usually insufficient for preventing IFIS and thus I seldom utilise it as a preventative measure.

1. Chang DF, Campell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 31 (4), 664–673 (2005).

2. Chang DF, Osher RH, Wang L, et al. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology. 114(5), 957−964(2007).

3. Chang DF, Braga-Mele R, Mamalis N, et al. Clinical experience with intraoperative floppy-iris syndrome; results of the 2008 ASCRS member survey; for the ASCRS Cataract Clinical Committee. J Cataract Refract Surg. 34:1201–1209 (2008).

4. Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin staged approach. J Cataract Refract Surg. 32(10), 1611– 1614(2006).

 

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