Intraoperative floppy iris syndrome

Overview

Intraoperative floppy iris syndrome (IFIS) is a condition that can occur during cataract surgery, characterized by abnormal behavior of the iris, the colored part of the eye. It is most commonly observed during phacoemulsification procedures and is associated with an increased risk of surgical complications. IFIS is marked by a flaccid iris that billows in response to intraocular fluid currents, a tendency of the iris to prolapse through surgical incisions, and progressive pupil constriction during surgery. Awareness and management of IFIS are crucial to prevent intraoperative difficulties and postoperative complications.

Causes

The primary cause of IFIS is the use of certain systemic medications, most notably:

• Tamsulosin: An alpha-1 adrenergic receptor antagonist used to treat benign prostatic hyperplasia (BPH). It has a strong association with IFIS, even if discontinued prior to surgery.

• Other alpha-blockers: Such as doxazosin and terazosin, although their association is less consistent than tamsulosin.

• Other potential contributing factors:

  • Hypertension

  • Older age

  • Male sex

  • Use of antipsychotic or anticholinergic medications (rare cases)

Symptoms

Intraoperative floppy iris syndrome does not present with symptoms prior to surgery. It is diagnosed intraoperatively, based on characteristic features observed by the ophthalmic surgeon:

• Flaccid iris: The iris appears unusually floppy and moves abnormally with fluid currents.

• Iris prolapse: The iris tends to bulge or slip through surgical incisions.

• Progressive miosis: Constriction of the pupil during surgery, making the procedure more challenging.

These signs typically appear once the anterior chamber is entered and intraocular manipulation begins.

Diagnosis

IFIS is diagnosed clinically during cataract surgery. There are no preoperative symptoms or definitive tests to confirm the condition beforehand, but a thorough patient history can help identify those at risk:

• Medication history: Ask specifically about alpha-1 blockers like tamsulosin, even if taken in the past.

• Ophthalmic evaluation: No specific preoperative findings predict IFIS, but smaller pupils may increase suspicion.

• Intraoperative findings: Observation of iris billowing, prolapse, and intraoperative miosis confirms the diagnosis.

Treatment

There is no cure for IFIS, but it can be managed effectively during surgery using a combination of preventive strategies and intraoperative techniques:

• Preoperative planning:

  • Identify patients with a history of tamsulosin or other risk factors.

  • Consider discontinuation of tamsulosin prior to surgery if deemed safe, although stopping the drug does not always prevent IFIS.

• Intraoperative management:

  • Use of iris retractors or pupil expansion devices to maintain pupil size and control iris movement.

  • Intracameral phenylephrine or epinephrine: To stiffen the iris and reduce floppiness.

  • Viscoelastic agents: Dispersive viscoelastics can help stabilize the iris during surgery.

  • Modified surgical technique: Gentle fluidics and careful tissue handling to minimize iris trauma.

Prognosis

With proper recognition and management, the prognosis for patients with intraoperative floppy iris syndrome is generally good. However, IFIS is associated with increased risk of surgical complications such as:

• Iris trauma or bleeding

• Posterior capsule rupture

• Prolonged surgical time

• Postoperative inflammation

When surgeons are aware of the risk and employ appropriate techniques, these complications can often be minimized. Patients with IFIS typically recover well, but close postoperative monitoring is advised to ensure optimal outcomes.