The document discusses Intraoperative Floppy-Iris Syndrome (IFIS), a condition characterized by a floppy iris that is more prone to prolapse during cataract surgery. IFIS is associated with the use of alpha-1 blockers like tamsulosin that are commonly used to treat benign prostatic hyperplasia. Surgery on patients with IFIS can lead to complications like iris trauma, dropped lens, and vitreous loss. Multiple strategies are used during surgery to manage a floppy iris, including pharmacologic agents, viscoelastic devices, and mechanical dilating devices. While IFIS increases surgical difficulty and risk, ophthalmologists and urologists can work together through education and alternative

1. IFIS – Intraoperative Floppy-Iris Syndrome Fritz Allen 10-2010

2. IFIS Some slides were borrowed from David Chang with his permission

3. ASCRS White Paper JCRS 12/08

4. IFIS Poor pupil dilation Triad of (1) Billowing of a flaccid Iris stroma (2) propensity for iris prolapse toward the phaco and side port incisions (3) progressive intraoperative pupil constriction First described 2005 by Chang and Campbell Can be mild, moderate or severe

5. IFIS-Surgical Complications Iris Trauma Vitreous loss – one retrospective study as high as 70%) Dropped lens Retained cortex Dislocated iol Macular edema Decreased post op vision

6. Email from 5/5/09 Dear Perry, I regret to inform that I had another complication with another FLOMAX case yesterday. While I used intracameral epi, iris hooks, and had great visualization, I still managed to break capsule leave cortex, drop some nucleus. Then, shaken by the first case, I dropped a nucleus in my 2nd case of six yesterday. My confidence is at an ebb. I'm thinking of punting complicated cases for awhile, until i feel more confident.

7. IFIS No correlation between IFIS and eye color, diabetes , or pseudoexfoliation Seemed to be related to Flomax and BPH patients.

8. BPH- Benign Prostatic Hyperplasia Incidence 50% of men older than 50 90% of men older than 85 Patients have trouble with bladder emptying and urinary frequency

9. Tamsulosin (Flomax) The most commonly prescribed drug for treatment of lower urinary tract symptoms of benign prostatic hyperplasia (BPH)- also used short-term for renal calculi relaxes smooth muscle in the prostate and bladder neck Improves bladder emptying and reduces urinary frequency Systemic alpha 1 adrenergic antagonist

10. Alpha 1 antagonists Because vascular smooth muscle is mediated by alpha 1 receptors they can be used for hypertension. Postural hypotension can be a problem Terazosin (Hytrin) Doxazosin (Cardura) Alfuzosin (Uroxatral) - non subtype selective Silodosin (Rapaflo) selective alpha 1A

11. IFIS There are at least 3 human alpha 1 receptor subtypes-1A, 1B, and 1D Tamsulosin has a 20 fold greater affinity for 1A than 1D which accounts for it being more uroselective and with fewer cardiovascular side effects

12. IFIS Incidence one prospective study of 1298 cases showed tamsulosin accounted for only 26% of alpha 1 antagonists but for 71% all iris prolapse

13. The Effect of the α 1 -Adrenergic Receptor Antagonist Tamsulosin (Flomax) on Iris Dilator Muscle Anatomy Ricardo Santaella, MD, John Destafeno, MD, Sara Miller, PhD, Sandra Stinnett, DrPH, Alan Proia, MD, Terry Kim, MD Albert Eye Research Institute Duke University Medical Center Durham, North Carolina

14. Control Subject Tamsulosin Subject Light Microscopy Morphometric Results Representative sample photomicrographs * Indicates iris dilator smooth muscle. (H&E) Mean (micrometers) Tamsulosin group n=26 Control Group n=26 P-Value* Iris Dilator Muscle Thickness 6.62 (SD=2.22) 8.20 (SD=1.77) 0.004 Iris Stromal Thickness 275.98 (SD=68.17) 274.65 (SD=57.96) 0.925

15. Other BPH drugs Finasteride Dutasteride (Avodart) These are 5 alpha reductase inhibitiors and lower the level of the hormone dihydrotestosterone with reduction in prostate size over time and do not have associated IFIS Prostate Cancer Prevention Trial –NCI sponsored with 18000 men found finasteride reduces risk of prostate cancer by about 25% in men 55 and older

16. IFIS Management Strategies Severity determines approach – unfortunately there is no reliable way to predict severity in advance of surgery Pharmacologic Microincisional approaches Highly viscous or viscoadaptive ophthalmic viscosurgical devices (OVD) Low flow fluid parameters Mechanical dilating devices – hooks and rings

17. IFIS Partial thickness sphincterotomies and mechanical pupil stretching are ineffective and may make it worse

18. Pharmacologic Serum half-life is 2-3 days Stopping Flomax – benefit unproven - the effect can last years Intercameral injection of alpha 1 agonists – ie phenylephrine –can help with dilation and increase iris rigidity by increasing smooth muscle tone- Joel Shugar’s epi-Shugarcaine mixture (has greater effect if neo is not used preop Topical atropine 1% tid for 1-3 days preop:good preop dilation but not as good controlling size intraop – could cause urinary retention – do not stop flomax if using atropine

19. Intraoperative Techniques Well constructed wound Trypan blue-to visualize the capsule during phaco Low fluidics-lower bottle, lower aspiration(eg<25cc/min) and vacuum (<200mm HG) Use of viscoelastics – eg Healon 5

20. Mechanical Pupil Expansion Devices Iris retractors-6-0 or 4-0 in a diamond pattern with one subincisionally Rings such as the Malyugin ring

21. IFIS Combination of approaches depending on how severe.

22. ASCRS IFIS Survey 3/08 Chang DF, et al; Cataract Clinical Committee J Cataract Refract Surg (July) 2008; 34: 1201-1209 957 respondents 75% US 42% ( > 2 cases/mo) 23% ( >3 cases/mo)

23. IFIS - 2009 Unanswered ?’s Tamsulosin vs non-selective α -blockers Stop α -blockers preop? Best surgical strategy? Complication rate now? Should patients see EyeMD before starting α -blockers?

24. epi hooks H 5 atropine Multiple strategies Rings Other Favorite initial strategy for IFIS

25. 18% more difficult, same risk 65% more difficult, >risk 5% “ No different” Surgical difficulty with tamsulosin 13% very difficult, >risk 95% “ More Difficult” 5% 77% “ Greater Risk”

26. 23% >PC Rupture 52% > iris trauma 30%

27. Would you take tamsulosin ? (mild cataract) 36% “yes” 24% “cataract surgery 1st” 17% “take nonselective α -blocker” 23% “avoid all α -blockers”

28. What do Ophthalmologists really think? Surveys tend to bring out the macho and tend to go to high volume surgeons 55yo ophthalmologist in Kaiser NW recently had a kidney stone. Went to ER diagnosed and offered pain meds and Flomax – he refused the flomax even for one dose

29. Routine referral pre-tamsulosin? 41% “NO” 38% “ IF HX OR CATARACT” 21% “ ROUTINELY” VA Other α -blockers 58% “NO” 11% “ROUTINELY” 31% “IF HX CAT”

30. More education for prescribing MD? 91% Agree 3% Disagree

31. Prescribing MD Education Sallam A, letter JCRS 6-08 survey 85 PCPs (UK) 97% (62/64) unaware of IFIS 80% > 5 tamsulosin Rx /mo

32. MAS Ophthalmology Experience IFIS is real. Increased complications are encountered when we operate on these patients. Multiple strategies are used adding time, material expenses, surgeon stress. Scheduling adds 15 minutes to a cases for some surgeons. A ring is $100, hooks $24, viscoadaptives $50

33. MAS Terazosin (Hytrin) is the Kaiser first line alpha blocker Tamsulosin (Flomax) is second line but on the formulary Flomax is used a lot because it has less orthostatic changes and does not require titration of dose.

34. Ophthalmology and Urology Working Together Education of providers Discuss cataracts with patients and look at their eye notes in HC Use non selective alpha one antagonists Standardize orders for titration of hytrin