Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin

Abstract

Purpose To describe the use of intracameral phenylephrine to prevent the floppy iris syndrome seen in patients who are on the drug tamsulosin for benign prostatic hypertrophy, during cataract surgery. Setting Prince Charles Eye Unit, King Edward VII Hospital, Windsor, Berkshire, UK. Method Seven patients who were on systemic tamsulosin for benign prostatic hypertrophy received intracameral phenylephrine before capsulorexhis during their cataract surgery. Results There was a significant reduction in the amount of mobility of the iris, reduction in the expected fluttering, and sustained papillary dilatation. Conclusion Intracameral phenylephrine is a simple and effective tool to prevent the effects of floppy iris syndrome in those patients undergoing cataract surgery who are on systemic tamsulosin.

Management of Intraocular Floppy Iris Syndrome (IFIS) in Cataract Surgery

“…Intracameral injection of phenylephrine, an α-1 AR agonist, has been recommended to reverse intraoperative iris fluttering and pupil constriction (Manvikar & Allen 2006;Gurbaxani & Packard 2007). In both studies diluted phenylephrine 2.5% was used (Minims®, buffered with bisulphite and edetate).…”

Intracameral Mydriatics in Cataract Surgery

“…The presumed mechanism by which tamsulosin causes IFIS is by blocking   receptors in the iris dilator muscle, and thereby preventing mydriasis during cataract surgery. Certain measures can be taken to reduce the risk of surgical complications in patients with IFIS, including iris hooks, preoperative topical atropine (Masket and Belani 2007), and -perhaps most interesting in this context -intracameral phenylephrine or epinephrine (Gurbaxani and Packard 2007;Masket and Belani 2007). Manvikar et al first described the use of intracameral phenylephrine to enhance mydriasis in patients with IFIS (Manvikar and Allen 2006).…”

“…Intracameral mydriatics render slightly smaller pupils than topical mydriatics at a maximum dosage, but with intracameral mydriatics, the pupils do not contract intraoperatively, as with topical mydriatics. As insufficient adrenergic stimulation of the pupil dilator appears to be a major factor causing intraoperative pupil contraction during phacoemulsification cataract surgery (Antcliff and Trew 1997;Liou and Yang 1998;Backstrom and Behndig 2006), intracameral mydriatics containing an adrenergic substance is effective in re-dilating the pupil (Backstrom and Behndig 2006;Mori, Miyai et al 2010), and are also used to prevent intraoperative floppy iris syndrome (IFIS) (Gurbaxani and Packard 2007;Takmaz and Can 2007;Cantrell, BreamRouwenhorst et al 2008). With intracameral mydriatics, the patients perceive less initial glare from the operation microscope light, as the pupil is small at the beginning of the procedure.…”

Alpha antagonists and intraoperative floppy iris syndrome (IFIS) during trabeculectomy

“…In addition to meticulous wound construction, the use of a viscoadaptive agent such as Healon 5 TM iris hooks and intracameral phenylephrine have been described. 1,10 These are not applicable in trabeculectomy. Surgeons who routinely use an AC maintainer during trabeculectomy should be aware of this potential complication and screen for the use of alpha-1 antagonists in preoperative assessment.…”