Approaching Eyes With Intraoperative Floppy Iris Syndrome

Four years after intraoperative floppy iris syndrome (IFIS) was first described,1 there is still no clear preference among ophthalmologists for the surgical management of these cases, according to a survey conducted last year by the ASCRS Cataract Clinical Committee.2 In fact, when asked to name their preferred single method for IFIS, the most common response (33%) was “always employ multiple strategies” (Figure 1). One reason for the diversity of opinions and approaches is the variable range of IFIS’ severity. A prospective multicenter study of cataract surgery in 167 consecutive eyes of patients on tamsulosin rated IFIS as mild (billowing only), moderate (billowing and intraoperative miosis), or severe (billowing, miosis, and iris prolapse).3 Using this classification, 10% of the tamsulosin cases had no IFIS, 17% had mild IFIS, 30% had moderate IFIS, and 43% had severe IFIS. In general, I anticipate severe IFIS when the patient is taking tamsulosin and the pupil dilates poorly preoperatively. Another warning sign is billowing of the iris immediately upon the instillation of intracameral lidocaine. In contrast, if the pupil dilates well preoperatively, I expect mild-to-moderate IFIS, but I am still prepared for iris prolapse. Patients taking nonselective alpha-1 antagonists or who have stopped their alpha blockers for several months are most likely to display mild-to-moderate IFIS.4 Considering the variable severity of IFIS, it makes sense that certain strategies, such as pharmacologic approaches, may work well in some eyes but poorly in others.2,4 Clearly, it is to surgeons’ advantage to be familiar with several different strategies from which they may select according to the situation or that they may use in combination to achieve complementary benefits. Intracameral alpha agonists, such as epinephrine, illustrate this point well. In some eyes, injecting epinephrine results in signifiApproaching Eyes With Intraoperative Floppy Iris Syndrome