Intraoperative Floppy Iris Syndrome: Updated Perspectives

Intracameral phenylephrine for surgical mydriasis and intraoperative floppy-iris syndrome: systemic adverse effects and optimal dose

Phenylephrine, a potent sympathomimetic, induces mydriasis via iris dilator muscle contraction. Intracameral (IC) phenylephrine has been successfully used in cataract surgery for initial mydriasis, maintaining mydriasis, and management of intraoperative floppy-iris syndrome. Serious systemic adverse events (mainly cardiovascular) have been described with topical phenylephrine drops, but we found very little evidence of such adverse events associated with IC phenylephrine use. However, we suspect under-reporting of such adverse events, as they may instead be ascribed to anxiety, positioning, anesthesia, etc. Optimal dosage/concentrations for IC phenylephrine use in different purposes have not been fully studied. In the absence of robust evidence, we suggest that lower but effective IC phenylephrine concentrations are used: a lower concentration (0.31%), in conjunction with an anticholinergic and lidocaine, may be used for initial mydriasis. For management of intraoperative floppy-iris syndrome, 0.31% may be effective, though a higher concentration (1% to 1.25%) may be required.

Prospective analysis of anatomic features predisposing patients to intraoperative floppy iris syndrome

PURPOSE

To aid preoperative risk assessment by identifying anatomic parameters corresponding with a higher risk of intraoperative floppy iris syndrome (IFIS) during cataract surgery.

METHODS

Prospective cohort study of 55 patients with α1-adrenergic receptor antagonist (α1-ARA) treatment and 55 controls undergoing cataract surgery. Anterior segment optical coherence tomography (AS-OCT), video pupilometer, and biometry measurements were performed preoperatively and analyzed regarding anatomic parameters that corresponded with a higher rate of IFIS. Those statistically significant parameters were evaluated with logistic regression analysis and receiver operating characteristic (ROC) curve.

RESULTS

Pupil diameter was significantly smaller in patients who developed IFIS compared to those who did not develop IFIS (AS-OCT 3.29 ± 0.85 vs. 3.63 ± 0.68, p = 0.03; Pupilometer 3.56 ± 0,87 vs. 3.95 ± 0.67, p = 0.02). Biometric evaluation revealed shallower anterior chambers in the IFIS group (ACD 3.12 ± 0.40 vs. 3.32 ± 0.42, p = 0.02). Cutoff values for 50% IFIS probability (p = 0.5) were PD = 3.18 mm for pupil diameter and ACD = 2.93 mm for anterior chamber depth. ROC curves of combined parameters were calculated for α1-ARA medication with pupil diameter and anterior chamber depth, which yielded an AUC of 0.75 for all IFIS grades.

CONCLUSION

The combination of biometric parameters with history of α1-ARA medication can improve assessment of risk stratification for IFIS incidence during cataract surgery.

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.

Impact of intraoperative floppy IRIS syndrome in cataract surgery by phacoemulsification: Analysis of 622 cases

BACKGROUND

Small pupil syndromes, including IFIS, increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris.

MATERIAL AND METHODS

Single-center prospective observational study, carried out at the Hospital de l'Esperança - Parc de Salut Mar.

RESULTS

622 eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. 61 cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. 23 cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. 19 cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation. The mean surgical time was 13.80 min (Standard Deviation - SD: 4.01 min) in patients without IFIS and 16.93 min (SD: 4.32 min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a 'two-tailed' or bilateral t-Student test with a p value of 0.01.

CONCLUSION

Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than Tamsulosin or the performance of cataract surgery before starting these treatments.

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.

Role of pilocarpine use following laser peripheral iridotomy in eyes with refractory acute angle closure glaucoma: A case report and literature review

RATIONALE

Angle closure glaucoma (ACG) is one of the most emergent types of glaucoma in clinical practice. Laser peripheral iridotomy (LPI) could minimize pupillary block and prevent ACG from an acute attack. However, recurrent increase in intraocular pressure (IOP) may still occur despite successful LPI. The aim of this study is to highlight the importance of postLPI pilocarpine use and larger LPI size as well as to share some experiences of cataract surgery in patients with ACG.

PATIENT CONCERNS

A 63-year-old female was referred to our hospital for headache, and poor control of IOP in the right eye for 3 hours.

DIAGNOSES

The patient was diagnosed ACG in the right eye. Recurrence of ACG in the right eye and new-onset and recurrent ACG in the left eye were noted during follow-up, despite successful LPI. The diagnosis was confirmed through slit lamp and gonioscope examination.

INTERVENTIONS

The LPI size was enlarged and pilocarpine use was maintained at 2% (1 drop 4 times a day) in both the eyes. Finally, cataract surgery was performed in both the eyes.

OUTCOMES

No recurrence of ACG was noted during postLPI pilocarpine use in both the eyes. The postoperative IOP was stable for >6 months after cataract surgery without any surgical intervention or antiglaucoma medication use. No discomfort or major complication was observed.

CONCLUSION

This report highlights the importance of postLPI pilocarpine use and larger LPI size in patients with refractory ACG.

Alpha Blocker-Associated Intraoperative Floppy Iris Syndrome

Objective To evaluate the literature related to the use of alpha1-blockers and the risk of intraoperative floppy iris syndrome (IFIS), particularly in cataract surgery. IFIS is characterized by floppiness or billowing of the iris, iris prolapse, and progressive miosis, possibly leading to severe complications. It is thought to be associated with adrenergic alpha-1 receptor antagonists commonly used to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia. Data Sources A literature search was conducted in Pubmed, EMBASE, and Web of Science through May 2021 with MeSH terms and keywords 'intraoperative floppy iris syndrome,' ' adrenergic alpha-1 receptor antagonists,' and 'cataract surgery.' Study Selection and Data Extraction Relevant articles were reviewed and included. In addition, reference lists from identified publications were reviewed to identify additional reports and studies of interest. Data Synthesis Numerous reports have linked IFIS to multiple risk factors including age, gender, hypertension, and the use of adrenergic alpha-1 receptor antagonists, most notably tamsulosin. Tamsulosin selectively blocks the adrenergic alpha-1 receptor in the iris dilator muscle, preventing mydriasis during cataract surgery. Other adrenergic alpha-1 receptor antagonists, including terazosin, doxazosin, alfuzosin, and sildosin, have also been linked to IFIS; however, their relationship to IFIS is not as well defined. Conclusion Patients should be educated regarding potential adverse effects and discuss this with their health care providers prior to cataract surgery. In addition, health care providers should be aware of the adverse effect and take steps to reduce the risk of surgical complications.

Relationship Between Tamsulosin Use and Surgical Complications of Cataract Surgery in Elderly Patients: Population-Based Cohort Study

Purpose

Although several previous studies have investigated the relationship between tamsulosin use and surgical complications of cataract surgery, no population-based cohort study has been conducted for the Asian population. We aimed to investigate the relationship between tamsulosin use and surgical complications of cataract surgery in the Korean elderly population.

Methods

This nationwide population-based retrospective cohort study included elderly patients (≥60 years) who had undergone cataract surgery in the period from 2003 to 2015. Baseline characteristics were age, sex, income, residence, and systemic, and ocular comorbidities (glaucoma, myopia, eye trauma, diabetes mellitus with ophthalmic manifestations, severe cataract, age-related macular degeneration). The exposure of interest was tamsulosin use within 1 year before cataract surgery. Logistic regression model was used to evaluate the relationship of tamsulosin use with surgical complications of cataract surgery.

Results

The rate of surgical complications of cataract surgery was 0.88% (375/42,539) in the non-tamsulosin group and 0.83% (71/8,510) in the tamsulosin group. The groups showed no significant difference in the risk of surgical complications of cataract surgery in the unadjusted model [odds ratio (OR) = 0.946; 95% confidence interval (CI):0.733–1.220; P = 0.669]. Additionally, tamsulosin use was not significantly associated with surgical complications of cataract surgery in the fully adjusted model accounting for age, income, residence, and systemic and ocular comorbidities (OR = 0.997; 95% CI: 0.749–1.325; P = 0.981).

Conclusions

The rate or risk of surgical complications of cataract surgery does not change with tamsulosin use. We suggest that better surgical techniques and surgeons' cognizance of the patient's tamsulosin use could improve surgical outcomes, without increasing surgical complications.

Risk factors for posterior capsule rupture in cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To analyze the incidence and risk factors for posterior capsule rupture (PCR) in cataract surgery.

SETTING

European clinics affiliated with the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data were obtained from the EUREQUO. The database contains data on demographics, comorbidities, and intraoperative complications, including PCR for the study period from January 1, 2008, to December 31, 2018. Univariate and multivariate logistic regression analyses were performed to estimate the (adjusted) odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

We analyzed EUREQUO registry data of 2,853,376 patients, and 31,749 (1.1%) cataract surgeries were complicated by a PCR. Data were available of 2 853 376 patients, and 31 749 (1.1%) cataract surgeries were complicated by a PCR. The PCR rate ranged from 0.60% to 1.65% throughout the years, with a decreasing trend (P < .001). The mean age of the PCR cohort was 74.8 ± 10.5 years, and 17 29 (55.5%) patients were female. Risk factors most significantly associated with PCR were corneal opacities (OR 3.21, 95% CI, 3.02-3.41, P < .001), diabetic retinopathy (OR 2.74, 95% CI, 2.59-2.90, P < .001), poor preoperative visual acuity (OR 1.98, 95% CI, 1.88-2.07, P < .001), and white cataract (OR 1.87, 95% CI, 1.72-2.03, P < .001).

CONCLUSIONS

Risk factors for PCR were identified based on the EUREQUO, and the incidence of this complication is decreasing over time.

A transcriptome atlas of the mouse iris at single-cell resolution defines cell types and the genomic response to pupil dilation

The iris controls the level of retinal illumination by controlling pupil diameter. It is a site of diverse ophthalmologic diseases and it is a potential source of cells for ocular auto-transplantation. The present study provides foundational data on the mouse iris based on single nucleus RNA sequencing. More specifically, this work has (1) defined all of the major cell types in the mouse iris and ciliary body, (2) led to the discovery of two types of iris stromal cells and two types of iris sphincter cells, (3) revealed the differences in cell type-specific transcriptomes in the resting vs. dilated states, and (4) identified and validated antibody and in situ hybridization probes that can be used to visualize the major iris cell types. By immunostaining for specific iris cell types, we have observed and quantified distortions in nuclear morphology associated with iris dilation and clarified the neural crest contribution to the iris by showing that Wnt1-Cre-expressing progenitors contribute to nearly all iris cell types, whereas Sox10-Cre-expressing progenitors contribute only to stromal cells. This work should be useful as a point of reference for investigations of iris development, disease, and pharmacology, for the isolation and propagation of defined iris cell types, and for iris cell engineering and transplantation.

Silodosin as a predisposing factor of intraoperative floppy iris syndrome (IFIS): an observational propensity score-matching cohort study

PURPOSE

To evaluate the correlation between silodosin and intraoperative floppy iris syndrome (IFIS) and compare it with other a1-adrenergic receptor antagonists (a1-ARAs) and other factors predisposing to IFIS.

METHODS

From the patients who underwent phacoemulsification between 2014 and 2020, we identified all patients who, during their preoperative assessment, reported an a1-ARAs intake (exposed group). These patients were matched utilizing a propensity score matching analysis with an otherwise homogenous group of patients (control group) based on demographics and systemic/ocular comorbidities.

RESULTS

A total of 350 patients were included in each group. In the exposed group, 177 (50.6%) patients were exposed to tamsulosin, 105 (30%) to alfuzosin, 43 (12.2%) to silodosin. Regarding IFIS, it was observed in 21.5% of patients on tamsulosin (38/177), 11.4% on alfuzosin (12/105), 37.2% on silodosin (16/43), and 3.4% in the controlled group (12/350). In a multiple regression model analysis, the only two factors significantly associated with IFIS development were silodosin and tamsulosin yielding an adjusted odds ratio of 8.471 (95%CI 4.005-17.920) and 3.803 (95%CI 2.231-6.485), respectively.

CONCLUSION

Silodosin has been demonstrated as a predisposing factor, strongly correlated with IFIS development. These results should increase cataract surgeons' awareness to assess their patients preoperatively for exposure to silodosin carefully and employ the appropriate prophylactic measures to ameliorate the impact of silodosin intake on the surgical outcome.

Consequences of mechanical pupil dilation, a study based on the Swedish national cataract register

PURPOSE

To describe the outcomes and demographics of patients undergoing mechanical pupil dilation (MPD) during cataract surgery.

SETTING

All cataract procedures performed in Umeå University Hospital and Sunderbyn, Gällivare and Piteå hospitals reported to the Swedish National Cataract Register (NCR) during 2013-2019.

DESIGN

Retrospective cohort study based on the Swedish NCR and electronic patient records.

METHODS

The number of control visits, pre- and postoperative visual acuities, surgical complications/intraoperative difficulties, ocular comorbidities and postoperative treatment regimens were retrieved for all cataract procedures with MPD. For each procedure, the consecutive procedure in the NCR from the same clinic without MPD was chosen to form a control group. A multinominal regression analysis with MPD as the dependent variable was performed to identify factors and outcomes independently associated with MPD.

RESULTS

A total of 25 349 patients aged 18-97 years underwent cataract surgery in these hospitals during the study period. Of these, 653 (2.6%) had MPD. Factors such as pseudoexfoliations and capsule staining were over-represented among MPD eyes. As a group, eyes with MPD had more postoperative visits and more postoperative anti-inflammatory drops, and more frequently needed augmentation of the anti-inflammatory treatment at the first postoperative visit.

CONCLUSIONS

MPD is independently associated with a more complicated intra- and postoperative course with more follow-up visits and requires more anti-inflammatory treatment postoperatively. This information could be added to the postoperative counselling, and more postoperative anti-inflammatory treatment could be considered in cases with MPD.

Incidence and complications of retained lens fragment in the anterior chamber after uneventful cataract surgery in a United Kingdom tertiary center

PURPOSE

To analyze the outcomes of retained lens fragment (RLF) in the anterior chamber after uneventful cataract surgery.

SETTING

Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom.

DESIGN

Retrospective, observational cross-sectional study.

METHODS

A single-center, retrospective review was performed to identify patients who underwent RLF removal after uneventful phacoemulsification surgery between October 2012 and November 2018; 122 eyes from 121 patients were identified. Patient characteristics, clinical findings, visual outcomes, and need for subsequent surgical procedure were recorded. Main outcomes were change in corrected distance visual acuity (CDVA), and number and risk factors associated with additional surgery following RLF removal.

RESULTS

One hundred twenty-two RLF over a total of 98 467 uneventful phacoemulsification surgeries were identified, with an incidence of 1 (0.124%) in 807 operations. The mean CDVA improved significantly after RLF removal from 0.32 to 0.26 logMAR (SD 0.26) (P = .001). Six eyes (4.9%) had persistent corneal edema that required endothelial keratoplasty (EK) after a mean of 13 months after RLF removal (SD 12 months; median 8; range 4 to 35). Risk factors for EK include α-receptor blocker use (odds ratio [OR], 6.75; 95% CI, 1.069, 42.63), increased interval (month) between cataract surgery and diagnosis of RLF (OR, 1.29; CI: 1.080, 1.541), increased interval between cataract surgery and RLF washout (OR, 1.28; CI, 1.075, 1.522), and RLF diagnosis on gonioscopy (OR, 10.60; CI, 1.885, 59.59).

CONCLUSIONS

RLF is a rare complication of uneventful cataract surgery and appears more frequently in challenging cataract cases and myopic eyes. CDVA improved significantly after RLF removal, but approximately 1 in 20 eyes needed additional surgery-mainly EK for corneal decompensation.

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.

Intraoperative floppy iris syndrome: an updated review of literature

Intraoperative Floppy iris syndrome(IFIS) remains a challenge for surgeons during phacoemulsification. Initially, it was related to the use of tamsulosin, an alpha adrenergic receptor blocker used in benign prostatic hyperplasia. Subsequently, other alpha adrenergic receptor such as alfuzosin, terazosin and doxazosin alongwith different other class of medications and systemic risk factors were identified. Other class of medications includes 5-alpha reductase inhibitor, angiotensin receptor antagonist, benzodiazepines, antipsychotics and antidepressants. Other risk factors include increasing age, male gender, diabetes, hypertension and decreased preoperative pupil diameter. It is very important for surgeons to identify these risk factors preoperatively and take appropriate preoperative and intraoperative measures to tackle the dreaded complications of IFIS. Sometimes, it is important for an ophthalmologist to work in cooperation with physician and urologist to minimize the complications. In conclusion, awareness of the risk factors associated with IFIS, their detailed preoperative assessment and intraoperative measures and surgical intervention is crucial in addressing IFIS. Lack of awareness can turn a routine, uneventful surgery into one with significant visual morbidity.

Anesthesia Considerations for Cataract Surgery in Patients with Schizophrenia: A Narrative Review

Schizophrenia is ranked among the top 10 global burdens of disease. About 1% of people meet the diagnostic criteria for this disorder over their lifetime. Schizophrenic patients can develop cataract, particularly related to age and medications, requiring surgery and anesthesia. Many concerning factors, including cognitive function, anxiety, behavioral issues, poor cooperation and paroxysmal movements, may lead to general anesthesia as the default method. Antipsychotic agents should be continued during the perioperative period if possible. Topical/regional anesthesia is suitable in most schizophrenic patients undergoing cataract surgery. It reduces potential drug interactions and many postoperative complications; however, appropriate patient selection is paramount to its success. General anesthesia remains the primary technique for patients who are considered unsuitable for the topical/regional technique. Early involvement of a psychiatrist in the perioperative period, especially for patients requiring general anesthesia, is beneficial but often under-utilized. This narrative review summarizes the anesthetic considerations for cataract surgery in patients with schizophrenia.

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.