This document discusses Intraoperative Floppy Iris Syndrome (IFIS), which is a complication that can occur during cataract surgery characterized by a floppy iris that billows and prolapses. IFIS is primarily caused by the medication tamsulosin and can lead to surgical complications. The document provides tips for managing IFIS, including preoperative atropine, intracameral epinephrine, Healon 5, and iris hooks or pupil expanders during surgery. A thorough medication history is important to identify patients who may be at risk for IFIS.

1. Intra-operative floppy
iris syndrome..IFIS
By Dr.shakhawan.A

2. Intraoperative floppy iris syndrome (IFIS) is
a complication that may occur during
cataract extraction in certain patients. This
syndrome is characterized by a flaccid iris
which billows in response to ordinary
intraocular fluid currents, a propensity for
this floppy iris to prolapse towards the area
of cataract extraction during surgery, and
progressive intraoperative pupil constriction
despite standard procedures to prevent this.[

3. characterized by poor dilation of the
pupil, intraoperative progressive
miosis, billowing of the iris tissue, and
iris prolapse through the ocular
incisions during cataract surgery,IFIS
has been associated with increased
rates of surgical
complications, including capsular
rupture, vitreous loss, and the loss
of iris tissue.

4. Induced primarily by the alpha 1-a
inhibitor, tamsulosin (Flomax; Boehringer
Ingelheim Pharmaceuticals, Inc.), IFIS may
be associated with other
alphablockers, psychotropic drugs, and over-
the-counter agents such as saw palmetto.
Tamsulosin is considerably more likely to
induce IFIS than are other medications.

5. Flomax (tamsulosin), a medication
widely prescribed for urinary symptoms
associated with benign prostatic
hyperplasia. Tamsulosin is a selective
alpha blocker that works by relaxing the
bladder and prostatic smooth muscle. As
such, it also relaxes the iris dilator
muscle by binding to its postsynaptic
nerve endings.

6. IFIS may also be associated with other causes
of small pupil like synechiae,
pseudoexfoliation and other medications
(used for conditions such as glaucoma,
diabetes and high blood pressure). IFIS does
not usually cause significant changes in
postoperative outcomes. Patients may
experience more pain, a longer recovery
period, and less improvement in visual acuity
than a patient with an uncomplicated
cataract removal.

7. Management of IFIS (Intraoperative Floppy Iris
Syndrome)
An important part of the History is a medication history.
During the preop exam, it is helpful to have patients bring a
list of medications they are taking so that you can review it
with them. We know that the effect of the alpha-1 blockers
on the iris persists after discontinuing these drugs, so it is
also necessary to specifically ask patients if they have ever
taken one of these medications. In addition, it is helpful to
evaluate the level of pupillary dilation during the fundus
exam, as this may be an indicator of the severity of IFIS.

8. Various techniques for handling IFIS
include preoperative topical
atropine, intracameral epinephrine,
Healon 5, iris hooks, and pupil
expanders. Because of the spectrum
of presentations of IFIS, these
options do not always work equally
well in all patients.

9. Atropine: Atropine bid or tid for
1-3 days prior to surgery may be
helpful to achieve better dilation
if it is noted that the patient
dilates poorly during the exam.

10. Patients are also instructed to
continue their tamsulosin
therapy, due to the risk of acute
urinary retention with the use
of atropine

11. Epinephrine: Intracameral sulfite-free
preservative-free epinephrine (dilution of the
1:1000 solution with BSS ranging from 1:3 to 1:5)
may also help to further dilate the pupil.cause
direct stimulation of iris dilator muscle
Healon 5 works very well to enlarge the pupil and
stabilize the iris, but care must be used during
hydrodissection and phacoemulsification to prevent
blowing out the posterior capsule and creating a wound
burn, respectively.

12. Iris hooks and pupil expanders: These devices
are 100% effective at enlarging the pupil and
they also stabilize the iris.
If you are having difficulty with iris hooks, it may
help to do one or more of the following: create the
stab incisions as peripheral and parallel to the iris
plane as possible, only partially fill the anterior
chamber with OVD prior to placing the hooks, and
use a hook under/behind the cataract incision.
Pupil expanders do not require separate incisions
and can be inserted more rapidly. Do not distort the
shape or position of iris.