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Cataract Surgery | Apr 2014

IFIS: When Nothing Is As It Seems

Several management strategies are available for each stage of surgery and for a range of complications associated with this syndrome.

Since it was first described by Chang and Campbell in 2005,1 intraoperative floppy iris syndrome (IFIS) has become a major concern for cataract surgeons. The syndrome involves three telltale symptoms: (1) a billowing iris that does not reach stable mydriasis despite sufficient administration of dilating agents, (2) progressive intraoperative miosis, and (3) a tendency for iris prolapse during surgery (Figure 1). When IFIS is not anticipated or is not recognized by the surgeon, the risk for myriad intraoperative complications increases. The range of complications includes limited view of the surgical area and injury to the iris resulting from manipulation of the surgical instruments. In rare cases, posterior capsular rupture (PCR) can occur, leading to loss of lens material into the vitreous cavitiy.1-4

The cause of IFIS has been identified as the intake of systemic alpha-adrenoceptor antagonists (alpha-blockers), drugs prescribed in men for lower urinary tract syndromes such as benign prostatic hyperplasia.1 The most popular drug of this kind, tamsulosin, has been shown to dramatically increase the risk for IFIS, and other drugs in the class have also been implicated.2,3 In their retrospective study, Chang and Campbell noted IFIS in 63% of patients taking tamsulosin, leading to a tenfold increase in PCR.1 A metaanalysis showed that the odds ratio for IFIS was elevated by a factor of 40 in tamsulosin patients.5


Looking at pharmacologic and pathophysiologic principles, two paths are responsible for IFIS: (1) The direct effect of alpha-blockers on iris receptors reduces the power of dilating agents and (2) ultrastructural changes lead to irreversible functional loss in the smooth muscle tissue of the iris and to chronic loss of muscular tension, with or without the presence of dilating drugs.6,7

At the start of surgery, a moderately dilated pupil can lead to an underestimation of problems to come. This treacherous period of peace often lasts until the moment of hydrodissection, when turbulence manifests in the anterior chamber. Suddenly, the extent of IFIS becomes visible in its entirety, and the iris moves with the least amount of intracameral flow. Iris prolapse and damage resulting from manipulation of surgical instruments, including pigment loss and stromal lesions, can lead to an unfavorable result.

Following is a list of pre- and intraoperative measures and techniques that can help one to avoid further complications in the event of IFIS, as well as one measure that seems logically as though it would help, but does not.


Include alpha-blockers in preoperative medical history. When general practitioners (GPs) conduct preoperative work-ups in patients taking alpha-blockers, in most cases their interest focuses on cardiovascular risks and patients’ use of anticoagulants, as the connection between the intake of alpha-blockers and intraoperative cataract surgery complications is largely unknown to primary-care physicians. In a study by Sallam et al, 96.8% of responding GPs stated that the correlation was unknown to them or not taken into account, and nearly 80% said they prescribed tamsulosin more than five times a month.8

This lack of information among GPs has been identified as the most salient risk factor for complications related to alpha-blocker intake, and, as a result, the number of published studies in urology, general, and family medicine journals describing IFIS outside the ophthalmic community has increased in recent years.9-11

Prescribe atropine eye drops. Although atropine is no longer in common use in ophthalmology because of its long duration of action, some surgeons prescribe topical use of this cycloplegic agent for 2 to 3 days prior to surgery for patients with known intake of alpha-blockers.12

Reduce intraocular pressure (IOP). To prevent uncontrolled iris movement and iris prolapse, a patient’s IOP should be lowered prior to surgery. The oral carbonic anhydrase inhibitor acetazolamide—if not contraindicated—and thorough use of oculopressure are effective for this purpose.

Discontinue the alpha-blocker? It seems only logical to discontinue a drug that can cause considerable complications. Unfortunately, this is not a solution to the problem. Tamsulosin and other alpha-blockers have long half-lives and can remain in the anterior chamber as long as 28 days after discontinuation.13 Moreover, alpha-blockers cause ultrastructural changes in the iris stroma that can prevent functional recovery long after discontinuation.6,7


Good preoperative preparation is important in the management of IFIS, but when the syndrome occurs intraoperatively there are a couple of aces you will be happy to have up your sleeve.

Apply intracameral epinephrine. In addition to dilating agents administered prior to surgery, intracameral sympathomimetic drugs can improve mydriasis and pupil tension in many eyes.14 In the late 1990s, Joel K. Shugar, MD, described a combination of epinephrine and a local anesthetic that he named epi-Shugarcaine.4,15,16 This mixture is still used today.

Employ viscomydriasis. If the pupil is poorly dilated despite the use of pre- or intraoperatively administered drugs, viscomydriasis with a high-viscosity ophthalmic viscosurgical device (OVD) is the next step to attempt to dilate the pupil and enhance anterior chamber stability.17 Completely filling the anterior chamber with a high-viscosity OVD can help to achieve mechanical pupil dilation and stabilization.17-19 If it is the surgeon’s preference, the high-viscosity OVD can be injected only in the area of the unstable iris or iris prolapse. With this method, the OVD acts as a barrier, and the rest of the anterior chamber can be filled with another OVD with different characteristics.20,21


Adjusting one’s surgical technique to the situation can help prevent or overcome intraoperative complications. For starters, some authors report improved anterior chamber stability using a bimanual microincision cataract surgery technique.3,22,23 When a clear corneal incision is used, the wound should be constructed longer than usual; however, under no circumstances should it be wider than needed for the instruments to pass through. If the incision is too large and outflow occurs around the phaco sleeve, iris prolapse can result.

The highest risk for iris prolapse is posed by the increase of intracameral pressure during hydrodissection, as there is no aspiration while fluid is injected into the anterior chamber in this maneuver. Forward movement of the iris-lens diaphragm when liquid is captured behind the lens can also trigger iris prolapse. When intracameral pressure rises, iris tissue can prolapse through the main or sideport incisions;3,18 this risk can be reduced by constructing the main incision as described above. Additionally, hydrodissection can be carried out through the sideport incision—rather than the main incision—to further reduce outflow and, thus, stabilize the anterior chamber.

During phacoemulsification, it is important to watch the pathologically mobile iris carefully to prevent iris prolapse and progressive miosis. In this phase, these complications can impair the surgeon’s view and potentially lead to damaging the iris tissue due to manipulations of the phaco probe (Figure 2). The use of an appropriate OVD along with proper phaco settings that include low irrigation and aspiration parameters can help avoid iris prolapse and progressive miosis.3

If iris prolapse occurs despite all these measures, injecting a high-viscosity OVD can reposition the tissue; however, in many cases this trick has limited use, as the OVD does not stay in place as it is supposed to.

In cases of repeated iris prolapse, iris hooks or a pupil expander should be placed before proceeding with phacoemulsification. As the positioning of four or five iris hooks is time-consuming and not always easy to accomplish in these difficult situations, iris expanders have become popular. It is important to remember: The earlier these devices are introduced, the easier they are to position and the better their effect.19,20,24,25

If these measures lead to no improvement of the situation, partial excision of the prolapsing iris tissue is the last resort.24


Many strategies and techniques are available for the management of IFIS and its complications preoperatively and at each stage of surgery. Ten guidelines for IFIS management are listed in the Take-Home Message.

An experienced surgeon will be able to rise to the challenge of dealing with IFIS using the techniques described here, but, as there is no gold standard, one tool alone stands out: communication.

Communication among all parties—the patient, the treating GP, the referring ophthalmologist, and the surgeon— remains the only reliable foundation on which to build one’s surgical planning. An informed surgeon can anticipate IFIS at an early stage when effective measures can still be taken. My advice for the cataract surgeon is simple: Talk, talk, talk.

Daniel M. Handzel, MD, FEBO, practices at Augenzentrum Osthessen in Fulda, Germany. Dr. Handzel states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +49 661 21075; fax +49 661 9019770; e-mail: dhandzel@augenaerzte-fulda.de.

  1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31(4):664-673.
  2. Mamalis N. Intraoperative floppy-iris syndrome associated with systemic alpha blockers. J Cataract Refract Surg. 2008;34(7):1051-1052.
  3. Chang DF, Braga-Mele R, Mamalis N, et al. ASCRS White Paper: Clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2008;34(12):2153-2162.
  4. Devgan U. Intraoperative floppy iris syndrome. Cataract & Refractive Surgery Today. 2009(10):89-90.
  5. Chatziralli IP, Sergentanis TN. Risk factors for intraoperative floppy iris syndrome: A meta-analysis. Ophthalmology. 2011;118(4):730-735.
  6. Prata TS, Palmiero PM, Angelilli A, et al. Iris morphologic changes related to alpha(1)-adrenergic receptor antagonists implications for intraoperative floppy iris syndrome. Ophthalmology. 2009;116(5):877-881.
  7. Santaella RM, Destafeno JJ, Stinnett SS, Proia AD, Chang DF, Kim T. The effect of alpha1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth muscle anatomy. Ophthalmology. 2010;117(9):1743-1749.
  8. Sallam A, Gunasekera V, Kashani S, Toma M. Awareness of IFIS among primary care physicians. J Cataract Refract Surg. 2008;34(6):882.
  9. Yaycioglu O, Altan-Yaycioglu R. Intraoperative floppy iris syndrome: Facts for the urologist. Urology. 2010;76(2):272-276.
  10. Handzel DM, Briesen S, Rausch S, Kälble T. Cataract surgery in patients taking alpha-1 antagonists: know the risks, avoid the complications. Dtsch Arztebl Int. 2012;109(21):379-384.
  11. Simpson D, Munshi S, Dhar-Munshi S. Intra-operative floppy iris syndrome—a warning for geriatricians. Age Ageing. 2010;39(4):516.
  12. Bendel RE, Phillips MB. Preoperative use of atropine to prevent intraoperative floppy-iris syndrome in patients taking tamsulosin. J Cataract Refract Surg. 2006;32(10):1603-1605.
  13. Parssinen O, Leppänen E, Keski-Rahkonen P, et al. Influence of tamsulosin on the iris and its implications for cataract surgery. Invest Ophthalmol Vis Sci. 2006; 47(9):3766-3771.
  14. Lorente R, de Rojas V, Vásquez de Parga P, et al., Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology. 2012;119(10):2053-2058.
  15. Shugar JK. Intracameral epinephrine for IFIS prophylaxis. Cataract & Refractive Surgery Today. 2006(9):72-74.
  16. Shugar JK. Use of epinephrine for IFIS prophylaxis. J Cataract Refract Surg. 2006;32(7):1074-1075.
  17. Auffarth GU. Viskoelastische Substanzen in der Ophthalmochirurgie. Bremen, Germany; UNI-Med Verlag: 2001.
  18. Allan BD. Mechanism of iris prolapse: a qualitative analysis and implications for surgical technique. J Cataract Refract Surg. 1995;21(2):182-186.
  19. Tint NL, Dhillon AS, Alexander P. Management of intraoperative iris prolapse: stepwise practical approach. J Cataract Refract Surg. 2012;38(10):1845-1852.
  20. Tint NL, Yeung AM, Alexander P. Management of intraoperative floppy-iris syndrome-associated iris prolapse using a single iris retractor. J Cataract Refract Surg. 2009;35(11):1849-1852.
  21. Arshinoff SA, Norman R. Tri-soft shell technique. J Cataract Refract Surg. 2013;39(8):1196-1203.
  22. Lockington D, Gavin MP. Intraoperative floppy-iris syndrome: role of the bimanual approach. J Cataract Refract Surg. 2009;35(6):964.
  23. Moore SP, Goggin M. Intraoperative floppy iris syndrome and microincision cataract surgery. J Cataract Refract Surg. 2010;36(11):2008.
  24. Chan DG, Francis IC. Intraoperative management of iris prolapse using iris hooks. J Cataract Refract Surg. 2005;31(9):1694-1696.
  25. Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: Results in 30 consecutive cases. J Cataract Refract Surg. 2008;34(5):835-841.