What Are Surgeons Doing About IFIS?

News of intraoperative floppy iris syndrome (IFIS) has caught the attention of ophthalmologists worldwide. It can make cataract surgery more difficult and has been associated with an increased complication rate.¹ My colleagues and I surveyed all of the consultant ophthalmologists within the UK to increase their awareness and gather information on the general epidemiology of IFIS. The survey also summarized their experience and the current options of IFIS' management (Nguyen D, unpublished data, 2006).

The survey's data provided an overview of what ophthalmologists had seen and were actually doing for IFIS. Fifty-three percent had encountered the syndrome either retrospectively or prospectively in male and female patients on tamsulosin as well as other alpha-receptor antagonists. Although 68% of consultants had patients discontinue taking tamsulosin preoperatively, they reported no consistent benefit from this step.

When questioned about how they preferred to manage floppy irides intraoperatively, 61% chose iris hooks, and 72% of that group had found the instruments to be effective (Figure 1). Twenty-seven percent of the ophthalmologists used Healon 5 (Advanced Medical Optics, Inc., Santa Ana, California) with low aspiration settings, and 85% found the technique to be effective. The use of intracameral phenylephrine was only recently described in the peer-reviewed literature,² and just 2% of respondents had used this method. Twelve percent, however, reported that they would consider this measure for future cases of IFIS. Other options for management less commonly used included bimanual microincisional phacoemulsification, mechanical pupil rings, and the preoperative administration of atropine.

The majority of UK consultants now directly ask patients about their history of prostate medication, and eye units have incorporated this question specifically into their preoperative assessment process. As a result, the potential problems associated with the use of alpha-receptor antagonists may be included as appropriate in the informed consent. These patients are educated about their increased likelihood of a technically difficult operation and possible complications including prolonged postoperative corneal edema, uveitis, glare, and dysphotopsia.

Ophthalmologists are challenged to minimize complications while improving surgical outcomes. An array of measures exists that can limit the effects of IFIS and prevent potential peri- and postoperative surgical complications. The true efficacy of intracameral phenylephrine and other techniques are as yet undetermined.

Although the prevalence, incidence, and associated risk factors of IFIS are not yet known, it is important to anticipate the potential operating difficulties with IFIS and the wide range of management options available. This edition of Cataract & Refractive Surgery Today Europe includes a series of articles describing the continuing evolution of strategies to manage IFIS safely. I believe that these articles will provide a unique and practical resource for clinicians.

Dan Nguyen, MRCOphth, is a specialist registrar for the Department of Ophthalmology at the Royal United Hospital Bath, in the UK. He states that he has no financial interest in the products or companies mentioned. Mr. Nguyen may be reached at +44 7971 929 856; danqbnguyen@hotmail.com.

1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31:664-673.
2. Gurbaxani A, Packard R. Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin. Eye. 2005 Nov 11; [E-pub ahead of print].