Review and Update of Intraoperative Floppy Iris Syndrome

Ahmed Sallam; Hany El-Defrawy; Adam Ross; Samer J Bashir; Hamish MA Towler


Expert Rev Ophthalmol. 2011;6(4):469-476. 

In This Article

Expert Commentary

Intraoperative floppy iris syndrome occurs in a significant number of patients with tamsulosin-associated cataract extractions. It is important that possible sequelae are anticipated and surgery is carefully planned, so that visual outcome is not adversely affected.[14,18,19] Based on available data,[9,18] we recommend that patients who are taking or have taken tamsulosin should only be operated on by senior cataract surgeons who have the capacity to handle complex cases and can employ compensatory measures to manage IFIS.

In our practice, we do not discontinue tamsulosin before surgery but we educate our patients about IFIS and its implications so that their consent is properly informed. For patients with a preoperative dilated pupil diameter of 6 mm or more, we do not employ any prophylactic measures; however, we prepare intracameral phenylephrine (1:360) and use it at the earliest signs of IFIS, if it is encountered. When used in such a context, phenylephrine is effective in decreasing iris flutter and prolapse as well as restoring preoperative pupil dilatation.[36] For cases with small pupil at the outset, we routinely use four iris hooks in a diamond configuration before performing the capsulorhexis, and more recently we have been using a 6.25 mm Malyugin ring with good success.

In our hands, neither the use of Healon5 nor preoperative atropine drops has been reliable for the management of IFIS. Despite the use of low–moderate fluidics, we find it difficult to maintain Healon5 in a sufficient volume in the anterior chamber to control the iris throughout surgery, and its effect is therefore short lived, even with repeat injections. Similar to the findings of the prospective tamsulosin trial,[18] we also find atropine drops insufficient for preventing IFIS and thus we seldom utilize it as a preventative measure.