Intraoperative floppy iris syndrome is a condition that most cataract surgeons have encountered. Since this side effect of systemic alpha-1 blockers (most notably tamsulosin (Flomax)) was first reported, we are much more knowledgeable about IFIS and management strategies. Our medicine and urology colleagues as well as patients are also more aware of the potential difficulties these medications cause with cataract surgery. It is included in the drug labeling and mentioned in the television ads.

IFIS has a spectrum of severity ranging from a normal iris response to an atonic iris that dilates extremely poorly and billows and prolapses during surgery. Therefore, some of the methods of managing IFIS do not work equally in every patient. Fortunately, there are many strategies we can utilize, and they can be selected alone or in combination depending upon the individual case. It has been well documented that patients with IFIS have an increased risk of complications at the time of cataract surgery such as iris trauma, posterior capsular rupture, and vitreous loss. Any cataract surgeon who has experienced this usually is not pleased to learn that Mr. Smith who is waiting in the next exam room to discuss cataract surgery is currently taking Flomax. However, the most important aspect of dealing with IFIS is being prepared. If you anticipate the potential intraoperative difficulties and are familiar with the treatment options, then you will be ready to manage IFIS effectively should the need arise.

An important part of the H&P is a medication history. During the preop exam, it is helpful to have patients bring a list of medications they are taking so that you can review it with them. We know that the effect of the alpha-1 blockers on the iris persists after discontinuing these drugs, so it is also necessary to specifically ask patients if they have ever taken one of these medications. In addition, it is helpful to evaluate the level of pupillary dilation during the fundus exam, as this may be an indicator of the severity of IFIS.

Various techniques for handling IFIS include preoperative topical atropine, intracameral epinephrine, Healon 5, iris hooks, and pupil expanders. Because of the spectrum of presentations of IFIS, these options do not always work equally well in all patients.

• Atropine: Atropine bid or tid for 1-3 days prior to surgery may be helpful to achieve better dilation if it is noted that the patient dilates poorly during the exam. I only have limited experience with this, but have not been impressed with the ability of atropine to dilate and stabilize the iris in patients with IFIS.

• Epinephrine: Intracameral sulfite-free preservative-free epinephrine (dilution of the 1:1000 solution with BSS ranging from 1:3 to 1:5) may also help to further dilate the pupil. I have tried this often for small pupils related to Flomax, and similar to my experience with atropine I have not been impressed with the results.
• Viscoadaptive OVD: Healon 5 works very well to enlarge the pupil and stabilize the iris, but care must be used during hydrodissection and phacoemulsification to prevent blowing out the posterior capsule and creating a wound burn, respectively.

Iris hooks and pupil expanders: These devices are 100% effective at enlarging the pupil and they also stabilize the iris. Iris hooks can be more difficult and time consuming to insert/remove and also create an irregularly shaped pupil that is often tented anteriorly toward the cornea. The reusable hooks are more rigid and easier to position. If you are having difficulty with iris hooks, it may help to do one or more of the following: create the stab incisions as peripheral and parallel to the iris plane as possible, only partially fill the anterior chamber with OVD prior to placing the hooks, and use a hook under/behind the cataract incision. Pupil expanders do not require separate incisions and can be inserted more rapidly. They also do not distort the shape or position of the iris. Such devices include the Malyugin ring, Graether 2000 pupil expander system, and Morcher pupil dilator. I only have personal experience with the Malyugin ring and have found it easy to use and very effective. The manual stretching technique of enlarging the pupil that is helpful in instances of a small pupil due to a bound-down, rigid iris should not be used in IFIS cases because it is not effective and can actually worsen the situation by increasing the floppiness of the iris.

Struggling through a cataract procedure with a small pupil and floppy iris is stressful due to the increased risk of complications; however, there are a variety of options we have to safely manage IFIS and significantly reduce the risk of these complications. The key to managing IFIS is being prepared, therefore, I suggest trying different methods and becoming familiar with them, so when necessary, you can comfortably handle the situation. Finally, a few words of caution regarding stopping the patient’s alpha-1 blocker…don’t do it! This strategy probably won’t help at all since IFIS does occur in patients who no longer use the medication (even years later), and discontinuing the drug can cause acute urinary retention.