Intraoperative floppy iris syndrome (IFIS) is a condition caused by systemic alpha-1 blockers (most notably tamsulosin (Flomax)). The iris dilator muscle becomes atonic to a variable degree causing poor pupillary dilation. During intraocular surgery, the pupil may constrict and the iris may billow and prolapse through the incisions.
Patients with IFIS have an increased risk of complications at the time of cataract surgery (i.e., iris trauma, posterior capsular rupture and vitreous loss). Numerous methods of managing IFIS have been described; however, because IFIS has a wide spectrum of severity ranging from a normal iris response to severe iris atony, the methods do not work equally well for every patient. Therefore it is important to be familiar with a variety of techniques, and tailor them to the individual case. The following is a summary of strategies for effectively managing IFIS and reducing the risk of surgical complications:
- Be prepared: Preoperatively, know if the patient is at risk and how well the pupil dilates. Specifically ask about current and prior use these drugs when obtaining the medication history. Prior use is important because even when only taken briefly, the effect on the iris persists after discontinuation. Evaluate the size of the dilated pupil—which often correlates with the severity of IFIS—and determine the etiology if the patient dilates poorly.
- Have a strategy: There are many techniques for dealing with IFIS including preoperative topical atropine, intracameral epinephrine, viscoadaptive OVD, iris hooks, and pupil expanders. These may be utilized individually or in combination:
- Topical atropine bid or tid for 1-3 days prior to surgery can be used to achieve better dilation. I find that atropine is only helpful in patients with mild IFIS.
- Intracameral sulfite-free preservative-free epinephrine (dilution of the 1:1000 solution with BSS ranging from 1:3 to 1:5) may also enlarge a poorly dilated pupil in patients with IFIS. Similar to my experience with atropine, I have not been impressed with the results of epinephrine.
- A viscoadaptive OVD, such as Healon 5, enlarges the pupil and stabilizes the iris in IFIS patients, but care must be used during hydrodissection to prevent blowing out the posterior capsule, and during phacoemulsification to prevent a wound burn.
- Iris hooks and pupil expanders are the most effective techniques for managing IFIS. Iris hooks can be more difficult and time consuming to insert and remove, and they create a square pupil. Pupil expanders (i.e., Malyugin Ring, Graether 2000 Pupil Expander, and Morcher Pupil Dilator) do not require separate incisions, can be inserted more rapidly, and do not distort the shape or position of the iris. Inserting a Malyugin Ring is my preferred method for managing IFIS. I find it easy to use and very effective.
Do not manually stretch the iris (as is commonly done for miotic pupils due to fibrosis from pseudoexfoliation syndrome, uveitis, etc.). This technique is not effective and can actually worsen the situation by increasing the floppiness of the iris.
Do not stop the patient’s alpha-1 blocker. It does not help because IFIS occurs in patients who no longer use the medication, even years later, and discontinuing the drug can result in acute urinary retention.