Advances in Cataract Surgery

Majed Alkharashi; Walter J Stark; Yassine J Daoud


Expert Rev Ophthalmol. 2013;8(5):447-456. 

In This Article

Intraoperative Floppy Iris Syndrome

Intraoperative floppy iris syndrome (IFIS) typically occurs in patients receiving α-1 blocker. Features of IFIS include poor pupil dilation; progressive intraoperative pupillary miosis, iris prolapse and floppy iris. To decrease the risk of complications, few peri- and intraoperative interventions have been successfully attempted. Pre-operatively, using atropine drops for few days is recommended.[12] Intraoperatively, short and posterior corneal wound construction should be avoided. Intracameral preservative free epinephrine may be utilized and adding preservative free epinephrine to a 500 ml BSS irrigation bottle is recommended (off-label). There should be a low threshold for using pupillary dilation devices. Because of the ability to place an iris retractor subincisionally, we prefer iris retractors to pupil expansion rings in IFIS cases with poor pupil dilation. Manual pupillary dilation and stretching should be avoided, so is overfilling and overly pressurizing the chamber with OVD. Some OVD should be removed by pressing on the wound before performing hydrodissection. Low fluidic parameters should be utilized, and suturing the main corneal incision to avoid iris prolapse in case of leaky wound. Arshinoff described modified soft-shell and ultimate soft-shell technique (SST-USST) for IFIS[13] which relies solely upon OVDs for iris stabilization by using Viscoat (Alcon.) and Healon5 (Abbott Medical Optics Inc.) to add a semi-rigid OVD roof to stabilize the iris and cause some viscomydriasis. Chang et al., reported that the use of preoperative atropine followed by intraoperative Healon5, iris retractors and pupil expansion rings resulted in excellent surgical outcome.[14]

Viscoat may be useful in compartmentalization especially in cases of localized weakness of the zonules (e.g., trauma). The reverse soft shell technique (packing Viscoat in a region of broken zonules followed by placing cohesive OVD over it to prevent vitreous from prolapsing) can be used in case of posterior capsule rapture to cover and stabilize the tear. Viscoat can also partition residual lenticular material from the prolapsed vitreous. In July 2012, Healon EndoCoat was approved by the US FDA as a dispersive OVD.