α1-Adrenergic Antagonists and Floppy Iris Syndrome: Tip of the Iceberg?

Effects of Alpha-Lytic Therapy Withdrawal on Choroidal Parameters in Intraoperative Floppy Iris Syndrome High-Risk Patients

Background/Objectives: The aim of this study is to investigate the effect on choroidal parameters of drug withdrawal in patients taking α1 adrenergic receptor antagonist (ARA) inhibitors. Methods: In total, 32 eyes of 32 patients under alpha-lytic therapy, and 32 eyes of 32 control subjects, both scheduled for cataract surgery in the fellow eye, were included. EDI-OCT was performed in all patients and subfoveal choroidal thickness (SFCT), luminal choroidal area (LCA), stromal choroidal area (SCA), total choroidal area (TCA), and choroidal vascularity index (CVI) during the preoperative visit were compared with data approximately 1 month after alpha-lytic withdrawal. The same assessments were performed in the control group. Results: SFCT and LCA were significantly reduced in the patients 1 month after alfa-lytic therapy withdrawal (p < 0.05), whereas in the control group, no changes in choroidal parameters were observed. Conclusions: The data proved that α1ARA inhibitors affected choroidal vessels, whereas no modification of choroidal stroma was observed.

Predictive value of pupillography on intraoperative floppy iris syndrome in preoperative period

AIM

To present the frequency of intraoperative floppy iris syndrome (IFIS) in cataract patients who taking alpha 1-a receptor antagonist (ARA) drugs, and evaluate the predictive value of pupil diameter (PD) changes in IFIS patients.

METHODS

Male cataract patients who are under treatment with alpha-1a-ARAs (alfuzosin, tamsulosin) intraoperatively were evaluated and were grouped as with/without IFIS. The preoperative PD values were compared with controls. Also, the intraoperative manipulations and early/late complications were recorded.

RESULTS

A total of 77 patients (77 eyes) of 94 benign prostate hyperplasia (BPH) patients have been defined as IFIS (81.91%) and 40 patients (40 eyes) were taking tamsulosin and 37 patients (37 eyes) were taking alfuzosin. During the cataract surgery, the rate of posterior capsular rupture (P=0.754), vitreous loss (P=0.585), iris tears (P=0.004), and iris catching (P=0.000) were higher in IFIS group, but the difference was significant only in the iris catching. At the postoperative first-month visit, persistent IOP rise and iris stromal tears were more frequent in IFIS group, but the difference was not significant (P=0.311, P=0.146; respectively). In contrast, Descemet membrane detachment was insignificantly more frequent in controls (P=0.311). In IFIS and control patients, PDs were 9.54±1.78 and 9.72±1.57 mm (P=0.255) under scotopic illumination, 8.54±1.43 and 8.74±1.25 mm (P=0.289) under mesopic illumination, 6.99±1.35 and 7.27±1.39 mm (P=0.662) under photopic illumination, respectively. However PDs were lower in IFIS under all illumination degrees, no significant difference was detected between groups.

CONCLUSION

IFIS is a significant clinical syndrome with an increased intraoperative/postoperative complication ratio. The prediction of this syndrome is important because of prevention required precautions against possible complications. There is no association between IFIS and preoperative PD.

Efficacy and safety of low-concentration, bisulphite-containing, intracameral epinephrine and topical atropine treatments for the prevention of intraoperative floppy iris syndrome

PURPOSE

The aim of this study was to evaluate the efficacy and safety of topical atropine and topical atropine combined with intracameral low-concentration, bisulphite-containing epinephrine treatment for the prophylaxis of intraoperative floppy iris syndrome.

MATERIALS AND METHODS

Seventy-two eyes of 55 male patients who were treated with alpha-adrenergic antagonist medications for benign prostatic hyperplasia were included in this study. Standard premedication with topical cyclopentolate, phenylephrine, tropicamide and ketorolac was applied to all of the patients. In 22 cases no further prophylactic method was used (Group-NP), while in 29 cases topical atropine drops was instilled 12 h and 30 min before surgery (Group-A) and in 21 cases 1:16 000 epinephrine was injected to the anterior chamber at the beginning of surgery (Group-EA) in addition to topical atropine prophylaxis.

RESULTS

In Group-NP, 62.8% of the cases developed IFIS, while development of IFIS was significantly lower in Group-A (17.2%, p = 0.0004) and Group-EA (9.5%, p < 0.0001). Posterior capsule rupture was observed in two cases (9.1%) in Group-NP, in one case (3.4%) in Group-A and was not observed in Group-EA. There was no statistically significant difference between the groups for the development of surgical complications. We did not observe any adverse events or significant endothelial cell loss (p = 0.462).

CONCLUSIONS

Our results indicate that preoperative use of topical atropine reduces the incidence of IFIS. Use of low-concentration, bisulphite-containing epinephrine is more effective in the prevention of IFIS and does not cause preservative related endothelial damage. This prophylaxis may be preferred when preservative free epinephrine is not available.

Intraoperative floppy-iris syndrome

OBJECTIVE

Intraoperative-floppy iris syndrome (IFIS) has been recently described. It has been demonstrated that this new syndrome complicates cataract surgery. In this paper we have reviewed the syndrome, and offer practical information specially related to the origin and management of this syndrome and we offer practical information.

MATERIAL AND METHODS

A review of the related medical literature using PubMed and Cochrane databases. Combining the search terms tamsulosin, cataract, IFIS and intraoperative floppy iris syndrome, more than 200 articles were found. Eighty-two of them were obtained and analysed. In the remaining only the abstract could be studied.

RESULTS

The aetiological association between IFIS and tamsulosin (and to a lesser degree between IFIS and other alpha-antagonists) is well established. Other aetiological associations are doubtful. Most of the literature is centred on cataract surgery. However, a similar syndrome has been described during trabeculectomy. A possible association between these drugs and choroidal detachments has also been described. Undoubtedly tamsulosin treatment makes cataract surgery more difficult and increases the probability of intraoperative complications. Protocols to manage the syndrome have not yet been developed. Intracameral injection of alpha-adrenergic agonists seems to be useful. However there is no evidence of the usefulness of discontinuing the drug or using preoperative mydriatics.

CONCLUSION

The aetiological and clinic features of the syndrome are well established. More studies are needed to provide scientific evidence on the most appropriate way to cope with this syndrome.

The floppy iris syndrome - what urologists and ophthalmologists need to know

INTRODUCTION

Benign prostatic hyperplasia (BPH) and cataract formation are common in older people. Medical management of symptomatic BPH is often preferred to surgical treatment as surgery increases the risk of morbidities, whereas, surgery is the main form of treatment to restore sight in patient with cataract. The clinical treatment of BPH is either alpha-1 adrenergic antagonist alone or combination of alpha reductase inhibitor and alpha adrenergic receptor (AR) antagonist. There are four alpha-AR antagonists currently available to treat BPH. The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin. Women are more likely to develop cataract than men and some recent studies showed that tamsulosin is effective in treating female lower urinary tract symptoms and thereby can cause IFIS during cataract surgery.

EVIDENCE ACQUISITION

We performed a critical review of the published articles and abstracts on association of IFIS with alpha-blockers and other medications as well as other medical conditions.

EVIDENCE SYNTHESIS

Tamsulosin is the most common cause of formation of IFIS. However, not all patients given tamsulosin develop IFIS and cases have been reported without any tamsulosin treatment.

CONCLUSION

Tamsulosin is a recognized cause to impede mydriasis and lead to IFIS during cataract surgery. Urologist should collaborate with their ophthalmology colleagues and general practitioner during prescribing tamsulosin in patients with history of cataract or waiting for planned cataract surgery. The increasing life expectancy and growth of older people will increase the number of men and women who suffer from lower urinary tract symptoms as well as cataract. Therefore, further research and studies are required to properly understand the relation of alpha blockers and IFIS.

Alpha antagonists and intraoperative floppy iris syndrome: A spectrum

Background

To determine occurrence of features of intraoperative floppy iris syndrome (IFIS) during cataract surgery in patients taking systemic alpha-antagonists (AA).

Methods

We prospectively studied patients on AA and who underwent phacoemulsification. The following were recorded: pupil diameter preoperatively, iris flaccidity, iris prolapse and peroperative miosis.

Results

We studied 40 eyes of 31 subjects. Mean age was 78 years. Overall, 14 eyes (13 patients) showed signs of IFIS: 9/13 (69%) eyes of patients on tamsulosin, 1/18 (6%) eyes in the doxazosin group, 2/2 prazosin patients, 1/4 eyes in the indoramin group, and 1/2 eyes in two patients on a combination of doxazosin and tamsulosin. Most cases (92%) had only one or two signs of IFIS. Bilateral cataract surgery was undertaken in 9 patients but only one patient (on tamsulosin) had features of IFIS in both eyes, while 4 patients (2 on tamsulosin and 2 on other AA) showed signs of IFIS in one eye only, and 4 patients did not show IFIS in either eye.

Conclusion

Most AA were associated with IFIS, but it tends to present as a spectrum of signs rather than full triad originally described. Tamsulosin was most likely to be associated with IFIS; however, its intake does not necessarily mean that IFIS will occur. For patients on AA, the behavior of the iris intraoperatively in one eye is a poor predictor of the other eye. Surgeons should anticipate the occurrence of IFIS in any patient on AA.

Intraoperative floppy iris syndrome (IFIS): a practical approach to medical and surgical considerations in cataract extractions

Intraoperative floppy iris syndrome (IFIS) during cataract surgery is characterized by iris fluttering, iris prolapse towards the incisions, and a progressive pupillary constriction leading to high rates of complications. The syndrome has been reported following the treatment of benign prostatic hyperplasia with α-1(a) adrenergic receptor inhibitors, especially tamsulosin. The present paper describes the syndrome and discusses its pharmacological background. Several techniques to prevent and to deal with the syndrome are presented.

Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin

PURPOSE

To evaluate the intraoperative findings, complication rates, effect of intracameral adrenaline, and incidence of intraoperative floppy iris syndrome (IFIS) in patients using tamsulosin.

METHODS

In this prospective nonrandomized observational study, 858 eyes of 774 patients who had phacoemulsification between August 2005 and November 2006 were evaluated. Duration and preoperatively discontinuing time of tamsulosin intake were questioned. Preoperative pupil size, intraoperative iris behavior, progressive miosis, adrenalin usage, and complications were recorded.

RESULTS

The incidence of IFIS was 1.6% and IFIS was seen in 14 of the 18 eyes of patients using tamsulosin (77.8%). One eye had floppy iris only, 2 eyes had floppy iris and intraoperative miosis, 3 eyes had floppy iris and iris prolapse, and 8 eyes had all three signs of IFIS. IFIS was seen in 7 of the 10 eyes where intracameral adrenaline was used, and in 7 of the 8 eyes without adrenaline (p=0.588). Intraoperative miosis was seen only in 3 of the 10 eyes with adrenaline and in 7 of the 8 eyes without adrenaline (p=0.025). Posterior capsule rupture occurred in 1 of the eyes with IFIS and in 5 eyes focal iris stromal atrophy caused by prolapse was seen.

CONCLUSIONS

IFIS occurred in 1.6% of cases having phacoemulsification. Intracameral adrenaline usage did not change the IFIS occurrence rate, but it seemed to be effective in preventing intraoperative miosis. There are still many questions about IFIS, and there is need for future studies strengthening the understanding of IFIS.

Prospective Multicenter Evaluation of Cataract Surgery in Patients Taking Tamsulosin (Flomax)

PURPOSE

Intraoperative floppy iris syndrome (IFIS) caused by systemic alpha-blockers has been associated with an increased risk of cataract surgical complications when the surgeon was unaware of the medication history and did not anticipate its occurrence. This study was undertaken to evaluate the surgical outcomes and rate of complications when the ophthalmologist knew the patient was taking tamsulosin (Flomax, Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT) and used 1 of several strategies to manage IFIS.

DESIGN

Prospective multicenter nonrandomized observational series.

PARTICIPANTS

A total of 167 consecutive eyes in 135 patients taking tamsulosin and undergoing cataract surgery.

METHODS

Phacoemulsification was performed in conjunction with at least 1 of 4 different IFIS management strategies, namely, topical atropine preoperatively, iris retractors, pupil expansion ring, or use of viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters.

MAIN OUTCOME MEASURES

Severity of IFIS, incidence of operative or postoperative complications, and final visual acuity.

RESULTS

The IFIS severity was rated as mild in 17%, moderate in 30%, and severe in 43% of the study eyes. No IFIS was noted in 10% of the eyes. The rate of posterior capsule rupture and vitreous loss was 0.6% (1/167; 95% confidence interval, 0%-1.8%). Ninety-five percent of eyes achieved a best-corrected visual acuity of at least 20/40.

CONCLUSION

When experienced surgeons could anticipate IFIS and employ compensatory surgical techniques, the complication rate from cataract surgery was low and the visual outcomes were excellent in eyes of patients with a history of tamsulosin use.

Floppy iris behaviour during cataract surgery: associations and variations

AIM

To assess the association of floppy iris behaviour during cataract surgery with use of alpha-1-antagonists and diabetes mellitus.

METHODS

1842 eyes of 1786 patients undergoing phacohoemulsification surgery were prospectively enrolled. The use of commonly prescribed alpha-1-antagonists and the presence or absence of diabetes mellitus were noted. The occurrence of any of the features of the intraoperative floppy iris syndrome (IFIS) was noted by surgeons blinded to the patient's history.

RESULTS

57% of patients receiving tamsulosin showed features of IFIS compared with 1% of the non-tamsulosin group (p<0.001). Of these, more than half the patients manifested the syndrome in an incomplete form. Only 1 of the 51 patients receiving other alpha-1-antagonists had IFIS. Diabetes was also not associated with IFIS (p = 1).

CONCLUSIONS

Tamsulosin is significantly associated with floppy iris behaviour during cataract surgery. But not all of these patients will necessarily show all or any features of IFIS. The floppy iris syndrome is likely to represent a continuum of severity. Various undefined factors, diabetes not being one of them, may have a contributory role. Non-selective alpha-1-antagonists are unlikely to be associated with IFIS.

Cataract surgery management in patients taking tamsulosin staged approach

PURPOSE

To demonstrate a progressive approach to the problems of intraoperative floppy-iris syndrome (IFIS) in cataract surgery caused by tamsulosin.

SETTING

Cataract Treatment Center, Sunderland Eye Infirmary, Sunderland, United Kingdom.

METHODS

Thirty-two eyes of 20 patients who were using tamsulosin had cataract surgery by the same surgeon using the same technique. Patients received standard preoperative eyedrops consisting of topical cyclopentolate, phenylephrine, and diclofenac. When necessary, intracameral phenylephrine, iris hooks, or both were used. All cases were videotaped and analyzed for surgical complications.

RESULTS

The degree of IFIS manifested varied widely in the patients: Seventeen of 32 eyes (53%) had good mydriasis preoperatively (type 1 and type 2 pupils); however, in 7 of the 17 eyes (43%), the pupils constricted later during surgery (type 2 pupils). Twelve eyes (38%) had a mid-dilated pupil that sometimes constricted later (type 3 pupils), and 3 eyes (9%) had poor dilation at the beginning of surgery (type 4 pupils). There were no surgical complications attributed to IFIS. Full IFIS manifestation varied between eyes of the same patient. Some eyes required no intervention. Intraoperative pupil constriction was reversed with intracameral phenylephrine, which also prevented iris prolapse and billowing and further pupil constriction in patients who had medium to small pupils preoperatively.

CONCLUSION

A staged approach in managing pupils in IFIS and using phenylephrine intracamerally when necessary effectively prevented serious intraoperative complications.