Since 2005, intraoperative floppy iris syndrome (IFIS) has become a well-documented complication of cataract surgery, with Chang and Campbell describing the condition in great detail.¹ It is not my intention to write another overview article on IFIS; there have been many good articles published in recent years. But I want to provide a practical guideline for managing an unexpected IFIS case.

Let us suppose that you are suddenly confronted with an iris that starts to billow during hydrodissection. In these cases, you will notice the iris start to move around in a typical, floppy way upon initiation of ultrasound phaco. Figure 1 depicts the floppiness of an iris within 0.5 seconds of the ultrasound onset.

FOUR STRATEGIES
There are four strategies to managing such an IFIS case, all of which aim to stabilize the iris diaphragm: pharmacologic compounds, mechanical devices, ophthalmic viscosurgical devices (OVDs), and fluid dynamics. Here, I discuss each strategy and stress my personal preference of action.

Pharmacologic compounds. Intracameral epinephrine has been proven to stabilize the iris.² Dr. Shugar started using the combination of lidocaine and epinephrine (ie, epi-Shugarcaine) in 1997. A precise description of his technique is found in the May 2007 issue of CRST Europe.³ In the same issue, you will also find a mini focus on IFIS, describing techniques of managing this cataract complication. I rarely need epinephrine, but I always have it directly available whenever the pupil decreases significantly in size.

Mechanical devices. Some surgeons choose to stabilize the iris mechanically. In most operating theaters, iris hooks are available for this purpose. Recently, however, several surgeons have reported a preference for the Malyugin Ring (MicroSurgical Technology, Redmond, Washington) over iris hooks and other pupil-sustaining rings.⁴ I have no experience with these devices; however, according to the literature, their use is promising.

OVDs. A viscoadaptive OVD, such as Healon5 (Advanced Medical Optics, Inc., Santa Ana, California) or dispersive, such as Healon D (Advanced Medical Optics, Inc.) or Viscoat (Alcon Laboratories, Inc., Fort Worth, Texas) forms a barrier between the iris and intracameral fluid streams. I prefer to use Viscoat to stabilize the iris; a lower molecular weight OVD does not cause high pressure spikes postoperatively. It is likely some of the OVD will remain in the eye in a floppy iris case.

Fluid dynamics. I have been able to manage IFIS with the combination of a suitable OVD and very low flow fluid dynamics settings.⁵ The key issue is that a floppy iris moves with the fluid streams in the eye. High fluid streams in the anterior chamber will drag the floppy iris along wherever the fluid is going (eg, toward the phaco tip or leaking incisions). It is therefore essential to follow a strategy to minimize fluid movements in the eye. I'll try to explain my step-by-step strategy:

1. Eliminate leak flow through the main incision, making sure that the phaco sleeve closes off the main incision completely. One should even consider creating a new incision if necessary.
2. Minimize leak flow through the sideport incision. If the initial sideport is too large, one should consider making a new one—as small as possible.
3. Minimize the infusion pressure by lowering the bottle as low as 40 to 50 cm. (A high infusion pressure increases leak flow.)
4. Reduce aspiration flow settings to low levels (ie, 12–15 mL/min).
5. Minimize aspiration flow by maintaining occlusion as much as possible. Torsional ultrasound facilitates minimal aspiration because of the minimal intrinsic repulsion. With longitudinal ultrasound, one can reduce repulsion by lowering ultrasound on-time (ie, duty cycle).
6. Reduce surge flow by using moderate vacuum levels. A sudden high surge flow on occlusion break can easily catch a floppy iris into the phaco tip.
7. Inject a dispersive or viscoadaptive OVD around the entire iris—not only on top of the iris, but also underneath the iris circumferentially. With the recommended aspiration flow levels, the OVD will remain in place and prevent the iris from moving with the (low) fluid streams in the anterior chamber.

CONCLUSION
In my hands and with my level of experience, I have been able to safely manage all IFIS cases using the strategy of combining a dispersive OVD with low fluidics and torsional ultrasound. In essence, I wrap the OVD around the iris. I also recommend a low flow setting for specific and complicated cases, such as IFIS.

Khiun F. Tjia, MD, is an Anterior Segment Specialist at the Isala Clinics, in Zwolle, Netherlands. Dr. Tjia is the Co-Chief Medical Editor of CRST Europe. He states that he is a research consultant to Alcon Laboratories, Inc. Dr. Tjia may be reached at e-mail: kftjia@planet.nl.

1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31(4):664-673.
2. Packard RB. Phenylephrine for IFIS. Cataract & Refractive Surgery Today Europe. 2007;2(4):23-24.
3. Shugar JK. Intracameral Epinephrine for IFIS Prophylaxis. Cataract & Refractive Surgery Today Europe. 2007;2(4):34-35.
4. Malyugin B. Malyugin Ring for Small Pupil Phaco Cases. Cataract & Refractive Surgery Today Europe. 2008;3(2):59-62.
5. Tjia KF. A Low Fluidics Parameters Strategy A Low Fluidics Parameters Strategy. Cataract & Refractive Surgery Today Europe. 2007;2(2):52-53.