intraoperative floppy iris Syndrome : update 2012

α-BlOcKeRS anD iFiS Tamsulosin was reportedly introduced in Japan in 1993, in the United Kingdom in 1997, and in the United States in 1997. Gupta et al related the popularity of the drug to its high affinity for the α1A receptor, which explains the lower incidence of adverse cardiovascular events in patients taking tamsulosin compared with less selective α-adrenergic blockers.3 Additionally, they identified three intraoperative findings associated with IFIS: (1) fluttering and billowing of the iris by ordinary intraocular currents, (2) the tendency of the iris to prolapse toward the site of the incision in the eye, and (3) progressive constriction of the pupil during surgery. Gani et al reviewed the ophthalmologic side effects of urologic medications. The investigators evaluated tamIntraoperative floppy iris syndrome (IFIS) was first described in 2005 by Chang and Campbell as a syndrome specific to the use of tamsulosin (Flomax; Boehringer Ingelheim Pharmaceuticals, Inc.).1 Commonly used for the treatment of benign prostatic hypertrophy, this α1A-adrenergic receptor blocker relaxes the bladder neck and smooth muscle of the prostate gland. Although tamsulosin is the most popular medication associated with IFIS, investigators have characterized IFIS as a syndrome that can occur to a lesser degree with other α-blocking medications used for the treatment of hypertension, renal colic, and voiding dysfunction in women.2 This month’s installment of “Peer Review” focuses on the most current articles available on this problem. Cataract surgeons’ aim is to reduce intraoperative complications associated with IFIS and iris prolapse in general. Having extensive personal experience with the management of IFIS over the past 15 years, I have used all of the techniques described herein to manage a floppy iris during cataract surgery. For several years, I used preoperative atropine, iris hooks, and intraoperative epinephrine. Although these modalities help, they do not eliminate IFIS. For pupils smaller than 5 mm after preoperative dilation, I routinely instill preservative-free epinephrine to aid the dilatory process and improve iris muscle tone. If the iris does not respond, I will place a Malyugin Ring (MicroSurgical Technology) to improve visibility and prevent the iris from presenting to the phaco needle. In my experience, the most prevalent factor resulting in iris prolapse due to IFIS is an increase in vitreous pressure. At the Freedom Vision Surgery Center in Encino, California, my colleagues and I use multiposition operative beds, and I routinely elevate the head of the bed 20o to 30o above the 180o meridian (Figure). For generously proportioned patients, I will elevate the head of the bed up to 45o, while maintaining hyperflexion of the neck to keep the pupillary plane perpendicular to the operative microscope as best as possible. Although elevating the head of the bed can compromise my comfort during a case, in the past 3 years, this strategy has virtually eliminated complications of iris prolapse and the resulting segmental iris atrophy associated with IFIS in my OR. I hope you enjoy this installment of “Peer Review,” and I encourage you to seek out and review the articles in their entirety at your convenience.