Floppy Iris Syndrome: Don't Miss This Risk in Female Cataract Surgery Patients

Sumit (Sam) Garg, MD


May 06, 2019

Intraoperative floppy iris syndrome (IFIS) is a common occurrence for cataract surgeons. First described over a decade ago,[1] IFIS has traditionally been identified in men taking the alpha-1 adrenergic antagonist tamsulosin for benign prostatic hypertrophy. However, recent evidence has expanded the association of IFIS well beyond this population. We now recognize that various other alpha-1 adrenergic antagonists (eg, doxazosin, alfuzosin, terazosin, silodosin) can have similar clinical effects, although to a lesser degree than tamsulosin. The characteristics of IFIS can also be exhibited with some medications, supplements, and medical conditions (eg, finasteride, antipsychotic agents, donepezil, duloxetine, labetalol; saw palmetto; and brittle diabetes) that don't share the same mechanism. More important, some patients who don't have any identifiable risk factors for IFIS sometimes exhibit its clinical features.

Recognizing the risk factors before cataract surgery affects the surgical plan and often the outcome. In addition, discussing the increased risk for complications is an important part of the informed consent process.

A More Complicated Picture of Risk Among Males and Females

To explore the role of sex as a risk factor for IFIS, Tzamalis and colleagues[2] conducted a retrospective review of 3213 patients (3811 eyes) undergoing phacoemulsification surgery at a single tertiary care ophthalmic center over a 4-year period. Of the cases reviewed, 50.8% were in female patients (1937 eyes in 1678 patients) and 49.2% were in male patients (1874 eyes in 1535 patients).

They reported an incidence of 5.17% (n = 97) in male patients and 1.29% (n = 25) in female patients. Interestingly, 72.2% of male patients who exhibited IFIS had been on an alpha-1 adrenergic antagonist, but none of the female patients reported any exposure. Also noteworthy was that the risk for posterior capsular rupture was significantly less in male patients (9.28%) than in female patients (28%), despite the substantial number of male patients who had a preidentified exposure to an alpha-1 adrenergic antagonist. This highlights the importance of identifying the risk for IFIS before surgery so that surgeons can be better prepared.

Classically, IFIS is identified when a patient exhibits progressive miosis, iris billowing, and iris prolapse through corneal incisions. But, thankfully, we have various interventions to help, including iris expanders (rings/hooks) and intracameral medications, in addition to surgical techniques and phaco settings. In this study, though, the posterior capsular rupture rates noted above were in cases where no such interventions were used.

Although this study has some shortcomings, it successfully relays that women can have tendencies toward IFIS, resulting in a higher complication rate than men. Given the common misconception that IFIS is only associated with benign prostatic hypertrophy, one could assume that women don't get IFIS; however, many of us have probably had female patients exhibiting such tendencies during cataract surgery. As medications that cause IFIS are used more frequently in women for such conditions as bladder outlet obstruction and detrusor underactivity, and to assist in kidney stone passage in nephrolithiasis, their use needs to be captured during our preoperative review. The fact that the women with IFIS in this study did not report any use of alpha-1 adrenergic antagonists, but intraoperatively exhibited IFIS with a high rate of posterior capsular rupture, leads me to believe that we are missing other etiologic factors for the development of this syndrome—a topic that would certainly benefit from further study.

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