Ten years of intraoperative floppy iris syndrome (IFIS) in the era of α-blockers

Abstract

IntroductionThe use of alpha-1 receptor antagonists in the treatment of benign prostatic hyperplasia (BPH) has created a problem in ophthalmic surgery, the so-called intraoperative floppy iris syndrome (IFIS). This consists of a billowing iris, insufficient pupillary dilation with progressive intraoperative miosis, and protrusion of iris tissue through the tunnel and side port incision that are made for access to the anterior chamber during surgery. IFIS presents particular difficulties in cataract surgery which is carried out through the pupil with manipulations in the immediate vicinity of the iris. The complications range from poor visibility of the operative field to iris damage with the surgical instruments and to rupture of the posterior capsule, with loss of lens material into the vitreous body.Material and methodsA comprehensive literature review was performed using MEDLINE with MeSH terms and keywords ‘benign prostatic hyperplasia’, ‘intraoperative floppy iris syndrome’, ‘adrenergic alpha-antagonist’ and ‘cataract surgery’. In addition, reference lists from identified publications were reviewed to identify reports and studies of interest from 2001 to 2017.ResultsThe A total of 95% of experienced ophthalmologic surgeons reported that systematic treatment with tamsulosin represents a challenging surgical condition increasing the risk of complications. Alpha-blockers are commonly prescribed, with 1,079,505 packages of tamsulosin prescribed each month in 2014 in Austria. Dose modification may be one way to reduce the risk of IFIS. A lower incidence of IFIS was reported in patients on tamsulosin in Japan, but the recommended dosage was lower than that used in Europe and the US (0.2 mg vs. 0.4 mg).ConclusionsWe showed that not all patients taking tamsulosin experience IFIS. Moreover, larger investigations with a prospective design are needed, including studies to monitor the pre- and post-therapeutic ophthalmologic changes under tamsulosin, as well as urodynamic improvements resulting from this therapy.

<p>Intraoperative Floppy Iris Syndrome: Updated Perspectives</p>

“…[5][6][7][8][9][10] However, IFIS came in the spotlight when the therapeutic algorithm for the treatment of benign prostatic hyperplasia (BPH) suggested the intake of a1-ARA as the first line treatment, substituting surgical intervention. 13 Three subtypes of a1-adrenergic receptors (a1-AR) have been identified so far: a1 A , a1 B and a1 D . a1 A AR is the main regulator of smooth muscle tone in the human urinary system and dominates also the musculus dilatator pupillae.…”

“…24 The discontinuation of tamsulosin 4-7 days prior to surgery might be beneficial, although it does not prevent IFIS completely. 1,13 Due to its high OR and RR for IFIS, it is recommended that urologists inform their patients for the risk of IFIS before prescribing tamsulosin. Ideally, the ophthalmologist of the patient should be notified.…”

“…The discontinuation of drugs with a causative relationship to IFIS such as tamsulosin does not seem to fully eliminate the risk of developing IFIS although it might be helpful sometimes. 1,13 In their initial description, Chang et al concluded that withdrawal of tamsulosin 4-7 days prior cataract surgery might prevent IFIS in some cases but not completely. 1 Tamsulosin has a relatively long halflife and can irreversibly block a1 adrenoceptors or induce permanent iris atrophy.…”

“…9,10 Then, careful incision location and construction along with the use of less aggressive, low-flow phacoemulsification fluidic parameters are effective in controlling iris behavior and lead to milder cases of IFIS. 9,13 Further slight modifications such as gentle hydrodissection, minimization of in-and-out movements and keeping the irrigation flow above the iris plane could be helpful. 22 In addition, the use of anterior elongated corneal incisions has been reported to reduce the incidence and severity of IFIS for dilated pupils no less than 4.5mm.…”

Silodosin as a predisposing factor of intraoperative floppy iris syndrome (IFIS): an observational propensity score-matching cohort study

“…In the original report, IFIS was utterly attributed to the intake of tamsulosin, a uroselective a1-adrenergic receptor antagonist (a1-ARA), which is commonly prescripted to men as treatment of benign prostate hyperplasia (BPH) 1 . IFIS mostly became apparent after the revised clinical guidelines of BPH's treatment, which replaced surgical intervention with a1-ARAs as the rst-line treatment 3 . However, IFIS has subsequently been correlated with a plethora of predisposing factors, including demographics (male gender and advanced age), arterial hypertension and antihypertensive drugs, a poorly dilated pupil, and other medications such as other a1-ARAs (besides tamsulosin), nasteride, antipsychotics, and benzodiazepines [4][5][6][7][8][9][10] .…”