Floppy Iris Syndrome

About

Intraoperative floppy iris syndrome (IFIS) is related to the use of oral alpha-1 antagonist, especially tamsulosin, in patients undergoing cataract surgery.

Intraoperative floppy iris syndrome (IFIS) is a complication during cataract surgery that was first reported by Chang and Campbell in the year 2005. This condition was noticed in those patients who were taking the oral drug tamsulosin for some other purpose(1^✔ ✔Trusted Source
Intraoperative floppy iris syndrome

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Tamsulosin is a drug that belongs to a group called alpha-1 antagonists. It is commonly recommended to treat lower urinary tract symptoms of benign prostate hypertrophy. Besides acting on the prostate, they also act on similar receptors that are present in the muscles of the iris, the dark circular disc which determines the color of the eye.

Thus, a person who has taken oral tamsulosin before cataract surgery may suffer from a complication during surgery, which amounts to intraoperative floppy Iris syndrome. This syndrome is characterized by poor dilatation of the pupil of the eye (the central dark spot through which light enters the eye), flaccid iris, and tendency of iris prolapse through corneal incisions.

Besides tamsulosin, several other alpha antagonists including terazosin and doxazosin are associated with the IFIS.

ICD-10-CM Code for Floppy iris syndrome - H21. 81

IFIS can be prevented by taking a detailed history of the patient which should include the details of medications taken. The patient should specifically be asked about the intake of tamsulosin or any other alpha-blocker before the surgery. Thus, the ophthalmologist can take preventive measures to prevent complications arising during cataract surgery(2^✔ ✔Trusted Source
Intraoperative Floppy Iris Syndrome: Updated Perspectives

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Causes of Floppy Iris Syndrome

Oral intake of tamsulosin before cataract surgery is one of the significant risk factors associated with floppy iris syndrome.

Floppy iris syndrome is a complication during cataract surgery that commonly affects those individuals who have taken oral tamsulosin, especially for benign prostatic hyperplasia.

Benign prostatic enlargement commonly affects elderly males resulting in a problem with urination. The prostate, bladder neck, and urethra have some receptors (sites on which certain drugs act) called alpha-1 Blocking these receptors with alpha-1 antagonists helps to relieve the symptoms of benign prostatic enlargement and therefore these drugs are used for this purpose. However, the iris of the eye also has the same receptors. Therefore, as a side effect of these drugs, these receptors also get blocked when the drugs are taken orally. Thus, a person who takes an alpha-1 antagonist and undergoes cataract surgery may experience the ill effects of the drug on the eye, resulting in floppy iris syndrome(3^✔ ✔Trusted Source
Drugs for benign prostatic hypertrophy

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Thus, floppy iris syndrome is caused by alpha-1 receptor antagonists like tamsulosin, terazosin, alfuzosin, prazosin and indoramine(4^✔ ✔Trusted Source
Alpha Blocker-Associated Intraoperative Floppy Iris Syndrome

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In addition, there are other drugs which have additional alpha blocking properties and therefore are also associated with IFIS. These include:

• Beta blockers such as labetalol
• Antipsychotics such as chlorpromazine, zuclopentixole or risperidone.
• Antidepressants such as mianserin

Other drugs that have been associated with floppy iris syndrome are:

• 5-alpha reductase inhibitors such as finasteride, dutasteride
• Dietary supplements or health food products such as saw palmetto(5^✔ ✔Trusted Source
  About Intraoperative Floppy Iris Syndrome
  
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Symptoms and Signs of Floppy Iris Syndrome

Signs of floppy Iris syndrome include poor dilatation of pupil during eye surgery, flaccid iris and a tendency of iris prolapse through corneal incisions.

Tamsulosin causes loss of tone of the iris resulting in the following features during cataract surgery:

• Poor dilatation of the pupil, which is required during the surgery
• Floppiness of the iris
• Tendency of the iris to prolapse through incisions

Depending on the severity of the condition, floppy iris syndrome is classified into grades 0 to 3.

Floppy iris syndrome can cause complications during cataract surgery. These include damage to the lens, vitreous humor or the iris(2^✔ ✔Trusted Source
Intraoperative Floppy Iris Syndrome: Updated Perspectives

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Treatment of Floppy Iris Syndrome

The application of topical atropine and epinephrine prior to surgery can help reduce IFIS. Because epinephrine is more effective, it is a better alternative for those who do not have cardiovascular disease. Preoperative pupil dilation should be supplemented with topical nonsteroidal anti-inflammatory drugs (NSAIDs), which can inhibit cyclooxygenase and limit miosis produced by prostaglandin production.

Adding irrigation solution containing 1.0% phenylephrine and 0.3% ketorolac during surgery can prevent or lessen the severity of IFIS.

In most cases of progressive miosis, intracameral phenylephrine can minimise iris floppiness and enhance iris dilatation. However, phenylephrine may not act at all if the iris dilator muscle is significantly injured.

Many benefits of micro-incision cataract surgery include anterior chamber stabilisation, a lower risk of iris prolapse, and less intraoperative tissue injury with less intraocular inflammation. Small incision surgery can be beneficial in moderate cases of IFIS, but its effectiveness diminishes in more severe cases.

Maintaining mydriasis and preventing the iris from prolapsing during cataract surgery can help prevent and manage IFIS. Mechanical and pharmacologic treatments, as well as the use of intraoperative appropriate phacoemulsification fluidic conditions, can help achieve this. In severe cases of IFIS, the use of iris hooks, iris retractors, or expansion rings is the most dependable technique of preserving an appropriate pupil during cataract surgery. Iris retractors and hooks work best when arranged in a diamond configuration with incision just posterior to clear corneal incision(6^✔ ✔Trusted Source
Intraoperative Floppy Iris Syndrome: Pathophysiology, Prevention, and Treatment

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Risk Factors of Floppy Iris Syndrome

Medication

Alpha blockers (-adrenoceptor antagonists) such as tamsulosin, alfuzosin, silodosin, alfuzosin, and doxazosin have been linked to floppy iris syndrome.

Finasteride as 5-reductase inhibitors is another form of BPH medication that has been linked to IFIS.

Floppy Iris Syndrome is caused by medicines such as donepezil, duloxetine, diazepines, and antipsychotics such as chlorpromazine, quetiapine, risperidone, zuclopenthixol, and aripiprazole.

Gender and age

Although IFIS has been documented in an infant undergoing congenital cataract surgery, the elderly are the major patient population. Aging is associated with an increase in the incidence of IFIS, which is consistent with the rising prevalence of cataract and other aging-related degenerative illnesses. Another risk factor is gender. Males have a substantially higher incidence of IFIS than females.

Systemic illnesses

Hypertension has been linked to an increased risk of IFIS. A univariate study found that short axial length of the eye is strongly connected to IFIS, indicating that anatomical aspects of ocular structure may be a possible risk factor for IFIS.

A univariate study found that short axial length of the eye is strongly connected to IFIS, indicating that anatomical aspects of ocular structure may be a possible risk factor for IFIS(7^✔ ✔Trusted Source
A narrative review of intraoperative floppy iris syndrome: an update 2020

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IFIS (intraoperative floppy iris syndrome) develops in 2% of cataract procedures and is linked to a higher risk of surgical complications(8^✔ ✔Trusted Source
Floppy iris syndrome and cataract surgery

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Depending on the severity of the condition, floppy eyelid syndrome can be addressed. Surgery to tighten the afflicted eyelid may be required if the floppy eyelid condition is severe.

Prevention of Floppy Iris Syndrome

Floppy iris syndrome can be prevented with medications, use of mechanical devices and ophthalmic viscosurgical devices.

Some of the methods of avoiding the consequences of floppy iris syndrome during cataract surgery includes the following:

• Complete patient history: The patient should be asked about intake of medications at the time of surgery as well as in the past.
• Medications: Suspending the use of tamsulosin before surgery is found to be only partially effective. The syndrome can appear even years after discontinuation of the drug. In addition, suddenly stopping tamsulosin may result in urinary retention in the patient with problem
• Administration of local atropine a few days prior to the surgery has been tried to bring about dilatation of the pupil(9^✔ ✔Trusted Source
  Atropine Ophthalmic
  
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• Introducing adrenaline or phenylephrine in the anterior chamber displaces tamsulosin from alpha receptors and may assist in preventing floppy iris syndrome.
• Mechanical devices: These devices are also known as the mechanical pupil expansion devices. They help in obtaining an adequate area of the pupil by dilating it, prevents it from constricting and prolapse of iris. These include iris retractors, methacrylate rings, silicone rings, Malyugin ring, Graether, Perfect pupil and Morcher ring(10^✔ ✔Trusted Source
  Dilation devices in cataract surgery
  
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• Ophthalmic viscosurgical devices (OVDs): High density solutions like Healon5 (2.3% hyaluronidate) are sometimes used during cataract surgeries to reduce iris wobbling(11^✔ ✔Trusted Source
  Ophthalmic Viscosurgical Devices (OVDs) in Challenging Cases: a Review
  
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Prognosis of Floppy Iris Syndrome

Aging has become more widespread as medical and social conditions have improved, which is connected with an increased incidence of BPH and cataract. Because IFIS is strongly linked to patients receiving tamsulosin, a popular treatment for BPH, it is critical for both ophthalmologists and urologists to raise awareness of the link. Furthermore, effective preoperative risk assessment for IFIS and accompanying intraoperative procedures are critical to reducing complications(7^✔ ✔Trusted Source
A narrative review of intraoperative floppy iris syndrome: an update 2020

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