Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic α-1a antagonist medication (tamsulosin)

Floppy iris syndrome associated with specific medication intake: A narrative review

Intraoperative floppy iris syndrome (IFIS) is a cataract surgery complication that remains a challenge for eye surgeons. It is caused by the antagonism of alfa-1-adrenergic receptors within the dilator muscle of the iris, thus preventing the iris from dilation during a cataract surgery. The long-term blocking alfa-1 adrenergic receptors by the chronic use of a number of systemic medications may lead to permanent anatomical atrophy of the dilator muscle of the iris. The most common drugs associated with the development of IFIS are tamsulosin and other alpha-1 adrenergic receptor antagonists prescribed to patients with low urinary tract symptoms (LUTS). There are other systemic medications that have been reported to have increased risk for IFIS. It is crucial for the ophthalmologist to identify the high-risk patients prone to develop IFIS. Its presence may complicate the course of cataract surgery, ultimately negatively affecting visual outcome. Cataract surgery should be performed by an experienced eye surgeon using alternative pharmacological and surgical techniques. Interdisciplinary cooperation is essential to mitigate potential complications. Patients should be informed by their physicians about the need to report a medication history to their eye specialists, especially before cataract surgery.

Factors predisposing to intraoperative floppy-iris syndrome: An up-to-date meta-analysis

Intraoperative floppy-iris syndrome (IFIS) is an increasingly recognized condition that is proven to lead to higher rates of intraoperative complications. This study provides an updated systematic review and meta-analysis regarding all the identified factors predisposing to IFIS. The study was performed in accordance with the PRISMA guidelines. 38 studies were finally included in the meta-analysis. The factors that were found to predispose to IFIS significantly were male sex (odds ratio [OR], 4.25; CI, 2.58-7.01), hypertension (OR, 1.55; CI, 1.01-2.37), tamsulosin (OR, 31.06; CI, 13.74-70.22), finasteride (OR, 4.60; CI, 1.97-10.73), benzodiazepines (OR, 2.88; CI, 1.17-7.12), and antipsychotics intake (OR, 6.91; CI, 2.22-21.50). A decreased dilated pupil preoperatively was found predisposing to IFIS (weighted mean difference -0.93; CI, -1.19 to -0.67). Intracameral epinephrine, which was investigated as a potential prophylactic measure for preventing IFIS, did not reach statistical significance (OR, 0.29; CI, 0.08-1.06). A comprehensive preoperative assessment of all risk factors is vital to stratify the surgical risk, which is crucial in addressing IFIS because unanticipated IFIS could turn a routine surgery into one of significant visual morbidity.

Risk of intraoperative floppy iris syndrome among selective alpha-1 blockers—A consistency model of 6,488 cases

Selective α1-blockers are commonly administered to patients with lower urinary tract syndrome and benign prostatic hyperplasia, but may increase the risk of intraoperative floppy iris syndrome (IFIS). The purpose of this study aimed to clarify the risk of IFIS among various selective α1-blockers. Four databases were searched for prospective studies comparing alpha-1-antagonists. Data were pooled using the consistency model, and used risk ratio (RR) and mean difference (MD) for IFIS and pupil diameter, respectively. This study finally included 25 prospective comparative studies. Based on 51 direct comparisons with 6488 cases, risks of IFIS in patients who received tamsulosin [RR, 13.85; 95% confidence interval (CI): 7.34 to 26.11], terazosin (RR, 8.94; 95% CI 2.88 to 27.74), alfuzosin (RR, 7.73; 95% CI: 3.05 to 19.62), and doxazosin (RR, 3.88; 95% CI: 1.13 to 13.28) were significantly higher than those did not receive α1-antagonists. Based on 11 direct comparisons with 564 cases, as compared to no α1-antagonists, patients who received tamsulosin (MD, −0.36; 95% CI: −0.71 to −0.01) and alfuzosin (MD, −0.34; 95% CI: −0.62 to −0.07) showed smaller pupil diameter under mesopic light levels, while those received silodosin did not show significantly smaller mesopic pupil diameter than people without α1-antagonists. IFIS seems to be inevitable with the usage of α1-antagonists, and tamsulosin needs to be cautious due to the significantly higher risk of severe IFIS. With regard to silodosin, there is no strong evidence to support the uses of italthough it does not significantly decrease mesopic pupil diameter.

Dealing with floppy iris syndrome

PURPOSE OF REVIEW

The aim of this study was to review and summarize recent findings and advancements regarding intraoperative floppy iris syndrome (IFIS). Although many improvements have been made for the management of IFIS, it remains a challenging condition for surgeons. An understanding of the syndrome as well as the multitude of tools to mitigate risk of complication is important for surgeons operating on high-risk patients.

RECENT FINDINGS

A variety of management approaches have been modified and improved or further supported with new data, such as intracameral compounds, intraoperative devices and surgical techniques.

SUMMARY

An understanding of risk factors is important for the identification of at-risk patients. A variety of approaches can greatly reduce incidence of IFIS complications. Multiple management strategies should be utilized to further reduce risk during these difficult surgeries.

Comparison of Femtosecond Laser-Assisted and Ultrasound-Assisted Cataract Surgery with Focus on Endothelial Analysis

Femtosecond laser-assisted cataract surgery has the potential to make critical steps of cataract surgery easier and safer, and reduce endothelial cell loss, thus, improving postoperative outcomes. This study compared FLACS with the conventional method in terms of endothelial cells behavior, clinical outcomes, and capsulotomy precision.

METHODS

In a single-center, randomized controlled study, 130 patients with cataracta senilis received FLACS or conventional cataract surgery.

RESULTS

A significant endothelial cell loss was observed postoperatively, compared to the preoperative values in both groups. The endothelial cell counts was significantly better in the FLACS group in cataract grade 2 (p = 0.048) patients, compared to conventionally at 4 weeks. The effective phaco time was notably shorter in grade 2 of the FLACS group (p = 0.007) compared to the conventional. However, no statistically significant differences were found for the whole sample, including all cataract grades, due to the overall cataract density in the FLACS group being significantly higher (2.60 ± 0.58, p < 0.001) as compared to conventional methods (2.23 ± 0.42).

CONCLUSIONS

Low energy FLACS provides a better result compared to endothelial cell loss, size, and shape variations, as well as in effective phaco time within certain cataract grade subgroups. A complete comparison between two groups was not possible because of the higher cataract grade in the FLACS. FLACS displayed a positive effect on endothelial cell preservation and was proven to be much more precise.

A narrative review of intraoperative floppy iris syndrome: an update 2020

Intraoperative floppy iris syndrome (IFIS) is characterized by intraoperative floppiness or billowing of the iris, progressive miosis, and iris prolapse through the surgical wounds. It was originally reported about fifteen years ago, which was later identified to be closely associated with tamsulosin, the most commonly used α1 adrenoceptor antagonist for benign prostatic hyperplasia (BPH). A variety of risk factors, including age, gender, hypertension, axial length of the eye, 5α-reductase inhibitors, other α adrenoceptor antagonist and neuromodulators, have been connected with IFIS. If IFIS occurs during phacoemulsification surgery, complications such as corneal endothelial loss, iris trauma, posterior capsule rupture (PCR), high intraocular pressure and vitreous loss are significantly increased. Therefore, preoperative evaluation of high-risk patients and appropriate intraoperative intervention is crucial to avoid severe complications. This review summarizes the pathogenesis and clinical features of classic IFIS, and provides some clinical pearls to ophthalmologists that may help identify, prevent or reduce IFIS associated complications. Additionally, from the perspective of clinical occurrence of IFIS, there are some recommendations for urologists as well. In conclusion, both ophthalmologists and urologists should be aware of this special clinical situation and communicate with each other about their own fields. A multidisciplinary interaction is of importance to simplify potentially complicated clinical issues.

Comparison of refractive predictability and endothelial cell loss in femtosecond laser-assisted cataract surgery and conventional phaco surgery: prospective randomised trial with 6 months of follow-up

Objective

Femtosecond laser-assisted cataract surgery (FLACS) decreases the use of energy and provides a more precise capsulorhexis compared with conventional phaco surgery (CPS). The purpose of this study was to examine if the lower energy use in FLACS caused less endothelial cell loss compared with CPS and if there was a difference in refractive predictability between CPS and FLACS.

Methods and analysis

This was a randomised controlled study of 96 patients with a 6-month follow-up comparing one eye surgery by FLACS and the contralateral eye operated by CPS (divide and conquer technique). Both eyes had intraocular aspheric lenses implanted. Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), central corneal endothelial cell count and hexagonality (non-contact endothelial cell microscope) were assessed preoperatively at 40 and at 180 days postoperatively.

Results

The mean phaco energies were 6.55 (95% CI 5.43 to 7.66) and 9.77 (95% CI 8.55 to 10.95) U/S (p<0.0001) by FLACS and CPS, respectively. At day 40, the mean endothelial cell loss (ECL) was 344 cells/mm² (95% CI 245 to 443) by FLACS (12.89%) and 497 cells/mm² (95% CI 380 to 614) by CPS (18.19%) (p=0.027). At day 180, ECL was 362 cells/mm² (95% CI 275 to 450) in FLACS (13.56%) and 465 cells/mm² (95% CI 377 to 554) in CPS (17.03%) (p=0.036).

The mean absolute difference from the attempted refraction was 0.43 (95% CI 0.36 to 0.51) dioptres (D) at day 40 and 0.46 D (95% CI 0.39 to 0.53) at day 180 by FLACS compared with 0.43 D (95% CI 0.36 to 0.51) at day 40 (p=0.95) and 0.46 D (95% CI 0.37 to 0.52) at day 180 (p=0.91) with CPS.

Conclusion

ECL was significantly lower in FLACS compared with CPS at both day 40 and day 180. ECL was correlated to the energy used. We found no difference in refractive predictability or CDVA between the groups.

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study

PURPOSE

To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons.

SETTING

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

DESIGN

Retrospective chart review.

METHODS

All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed.

RESULTS

In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group 1 month after surgery (0.051 ± 0.10 [SD] versus 0.132 ± 0.30, P = .03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8 ± 26.5 minutes and 30.9 ± 12.6 minutes for cases performed by resident surgeons and attending surgeons, respectively (P  .0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P = .008). The overall rate of adverse events was no different between residents and attending surgeons (P = 0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P = .001).

CONCLUSION

Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.

Complications of cataract surgery in Wistar rats undergoing treatment with tamsulosin

The aim of the study was to identify if there is a connection between the time of administration of alpha-blocker medication and cataract surgery complications. Furthermore, it was explored whether discontinuation of tamsulosin before cataract surgery influences the manifestations of intraoperative floppy iris syndrome in rats. An experimental study was conducted on 20 male Wistar rats aged 1.5-2 years (body mean weight 357 g), which were divided into four equal groups: Group 1, under tamsulosin hydrochloride 0.4 mg/day for 2 months; group 2, without any treatment in the first month, followed by tamsulosin; group 3, under tamsulosin for 1 month, followed by 1 month without any treatment; and group 4, control. The pupillary diameter was assessed before instillation of 0.5% tropicamide (mydriatic and cycloplegic agent), after 1 or 2 h from instillation and postoperatively. Furthermore, pupil constriction during surgery, the presence of floppy iris and prolapse of the iris following the main incision and during serum injection were also assessed. Other analyzed features included iris rupture, posterior capsule tear, vitreous loss, lens fragments in the vitreous, suprachoroidal bleeding and corneal haze. The iris dilator muscle thickness and the posterior epithelium was measured using light microscopy. In the control group, the largest pupillary diameters were indicated and in group 1, the smallest pupillary diameters were revealed. Statistically significant differences were indicated between group 1 and 2 and group 3 and 4. Floppy iris, iris prolapse in the main incision and during serum injection appeared at maximum frequency for group 1 with continuous treatment and low frequency for the control group. Lens fragments in the vitreous were present in the groups 1-3. Notably, intraoperative miosis had statistical relevance in group 1 and group 2. To conclude, the present findings suggested there is a clear connection between the time of administration of the alpha-blocker medication and most cataract complications. The results indicated that discontinuation of tamsulosin for one month largely reduces the manifestations of intraoperative floppy iris syndrome in rats, which may suggest to change preoperative treatment for benign prostatic hypertrophy with another class of drugs that do not interact with the iris receptors.

Effects of phacoemulsification with versus without viscoelastic devices on surgical outcomes

PURPOSE

The aim of this study is to report surgical outcomes in patients undergoing phacoemulsification surgery (PE) with versus without ophthalmic viscosurgical devices (OVDs).

METHODS

This is a comparative case series study. In total, 145 patients who performed PE with OVDs in 68 eyes (Group 1) and without OVD in 77 eyes (Group 2) were enrolled. A comprehensive ophthalmological examination was performed including slit-lamp, fundus examination. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) specular endothelial microscopy (SM), and ultrasound pachymetry (UP) were also measured before surgery and at four-time points postoperatively. The differences in baseline characteristics as well as in outcomes were compared between the two groups.

RESULTS

The mean BCVA was 0.41 ± 0.26 logMAR in Group 1 and 0.54 ± 0.34 in Group 2 at postoperative first day, with a significant difference (p < 0.01). The mean BCVA, IOP, and UP at 6 months did not differ between the groups. The mean baseline and postoperative SMs were 2063 and 1910 cells/mm², respectively, and the endothelial cell loss (ECL) was 153.89 ± 189 in Group 1. The mean baseline and postoperative SMs were 2153 and 1948 cells/mm², respectively, and the ECL was 205 ± 200 in Group 2. The difference between the groups was not statistically significant (p = 0.105).

CONCLUSIONS

The ECL seemed to be higher in the Group 2, but the difference was not significant. The final clinical outcomes were similar between the groups. In selected cases, PE without OVD may be preferable to reduce the cost of surgery in places with low economic status and to prevent side-effects of these devices.

Floppy iris syndrome and cataract surgery

PURPOSE OF REVIEW

Intraoperative floppy iris syndrome (IFIS) occurs in 2% of cataract surgeries and is associated with an increased risk of surgical complications. These complications can be avoided when high-risk patients are identified by preoperative screening and appropriate measures are used intraoperatively. The purpose of this article is to review emerging risk factors for IFIS and to summarize management strategies used in IFIS.

RECENT FINDINGS

Although α1-antagonists in general, and tamsulosin (Flomax, Jalyn) in particular, have long been associated with IFIS, recent studies have more firmly demonstrated the elevated risk of IFIS attributed to tamsulosin. This resulted in a revision of the American Society of Cataract and Refractive Surgery/American Academy of Ophthalmology guidelines on IFIS. Our understanding of additional medications and medical conditions involved in IFIS is also evolving, including an appreciation that women are also susceptible to IFIS. New modifications of techniques used in the intraoperative management of IFIS are also discussed.

SUMMARY

Preoperative screening should include both men and women. Current or prior use of α1-antagonists and antipsychotics should be documented, along with hypertension. Surgeons should be prepared to employ a range of perioperative interventions in a graded response to IFIS of different severities.

Modified Surgical Techniques for Managing Intraoperative Floppy Iris Syndrome

Purpose. To report a modified surgical strategy in the management of intraoperative floppy iris syndrome-associated iris prolapse. Methods. Prolapsed iris is left as is and a new corneal incision near the original wound but at a different site is created. Depending on the location of the original incision and the surgeon's preference, this additional incision can be used as a new port for phacoemulsification tip or can be the new site for the iris to securely prolapse, allowing for the surgery to proceed safely. Results. We present 2 cases of iris prolapse and inadequate pupil dilation in patients with IFIS. Along with our modified technique, additional iris retractors were placed to increase the workspace for the phacoemulsification tip. The cataract surgery was performed successfully without further complications in both cases. Conclusion. This surgical technique could be an adjunct to allow the surgeons to expand the armamentarium for the management of IFIS-associated iris prolapse.

Corneal endothelial cell loss after pars plana vitrectomy and combined phacoemulsification-vitrectomy surgeries

OBJECTIVE

To compare postoperative corneal endothelial cell density (ECD) loss in eyes undergoing pars plana vitrectomy (PPV), or combination of cataract extraction (using phacoemulsification) and intraocular lens implantation with vitrectomy (CE/IOL-PPV) surgeries.

METHODS

Institutional setting. Best-corrected visual acuity (BCVA) and ECD by specular microscopy were measured preoperatively and 3 months postoperatively in both groups. Relative postoperative ECD loss was the primary outcome measure. Change in BCVA was the secondary outcome measure.

RESULTS

Forty eyes of 40 patients undergoing PPV and 46 eyes of 46 patients undergoing CE/IOL-PPV were included in the final analysis. Postoperative ECD was decreased slightly more in the CE/IOL-PPV group compared with the PPV group (13.9% ± 15.5% vs 9.0% ± 14.6%), although this was not statistically significant (p = 0.10). The improvement in the logMAR BCVA was, however, statistically more significant in the CE/IOL-PPV group compared with the PPV group (-56.6% ± 24.3% vs -38.6% ± 45.5%, p = 0.04).

CONCLUSIONS

PPV and the combination CE/IOL-PPV surgeries lead to modest and statistically similar postoperative decline in ECD. The combination surgery may lead to slightly more postoperative cells loss, but also more improvement in visual acuity.

Anterior segment morphologic changes related to α-1 adrenergic receptor antagonists use

PURPOSE

To investigate possible changes in anterior segment parameters with the Pentacam in patients taking tamsulosin or doxazosin for benign prostatic hyperplasia.

METHODS

This prospective, cross-sectional study was conducted at Necip Fazil City Hospital, Kahramanmaras, Turkey. Patients included in the study were grouped as follows: 29 patients treated with tamsulosin (group 1), 27 patients treated with doxazosin (group 2), and 40 untreated controls (group 3). Right eyes of each patient were included in the study. All patients underwent examination with the Pentacam under standard dim light conditions and with undilated pupils. Anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA) width, central corneal thickness (CCT), corneal volume (CV), and pupil diameter (PD) were recorded.

RESULTS

Mean duration of treatments was 2.7 ± 1.2 (1-5) and 2.4 ± 0.9 (1-5) years in groups 1 and 2 (p = 0.276). The ACD, ACV, ACA width, and PD were statistically significantly decreased in groups 1 and 2 when compared to group 3 (p&lt;0.05). There were no statistically significant differences among the groups in mean values of CCT and CV.

CONCLUSIONS

In this study, decreased ACD, ACV, ACA width, and PD values were detected in tamsulosin and doxazosin groups when compared to controls. These findings should be considered during anterior segment examinations and surgeries.

Small pupil and cataract surgery

PURPOSE OF REVIEW

Presence of a small pupil is still considered a major challenge for cataract surgeons. Appropriate mydriasis and maintaining it is of paramount importance to prevent potential serious complications. Recently, more interventions and instruments are available for the cataract surgeons to deal with these challenging cases. The intention of this review is to discuss the preoperative and intraoperative considerations and techniques for cataract surgery in small pupil and related conditions and to discuss new developments in management of small pupil in femtosecond laser-assisted cataract surgery.

RECENT FINDINGS

There are new techniques and pharmaceuticals available to cataract surgeons in the setting of small pupil. Intracameral ketorolac may soon be available to maintain mydriasis and to control pain and inflammation. Malyugin ring has been added to pupil expansion rings and has already been used for small pupil in different settings. In femtosecond laser-assisted cataract surgery, presence of a small pupil can now be managed by applying intracameral mydriatics and intraocular devices successfully.

SUMMARY

Accurate preoperative examinations adjunct with intraoperative use of appropriate pharmacologic and mechanical devices can yield favorable outcomes in cataract surgery with a small pupil.