UNRECOGNIZED INTRAOPERATIVE FLOPPY IRIS SYNDROME IN A PATIENT ON PROSTATE MEDICATION UNDERGOING CATARACT SURGERY IN 2004: A RETROSPECTIVE CASE STUDY
This case study describes a 2004 incident involving a patient who experienced significant intraoperative challenges during cataract surgery due to iris behavior consistent with what is now known as Intraoperative Floppy Iris Syndrome (IFIS). At the time, the association between IFIS and alpha-1 adrenergic antagonists—particularly tamsulosin—had not yet been established. This case illustrates the importance of thorough medication history and evolving awareness of drug-related surgical risks.
CASE PRESENTATION:
A general surgeon was referred to the Bochner Eye Institute in 2004 for evaluation and management of bilateral cataracts. At presentation, his best corrected visual acuity was 20/60 in the right eye and 20/40 in the left eye. Slit-lamp examination revealed 2–3+ nuclear sclerosis and 2+ cortical changes in both eyes. Pupillary diameter was noted to be 3.5 mm, with maximal dilation limited to 5 mm bilaterally.
After discussion of risks and benefits, the patient proceeded with cataract extraction. Intraoperatively, the iris behavior was atypical: upon creation of the initial microincision, the iris prolapsed and plugged the wound. Additional viscoelastic was required to reposition the iris. Similar behavior was observed during entry through the main incision. Despite surgical difficulty, the cataract was removed and a posterior chamber intraocular lens (PCIOL) was implanted. One week later, the second eye was operated on, and the same intraoperative iris floppiness was observed.
At the time, no specific cause for the abnormal iris behavior was identified.
DISCUSSION:
In hindsight, this patient’s intraoperative complications align with Intraoperative Floppy Iris Syndrome (IFIS), a condition formally described in 2005 by Chang and Campbell. IFIS is characterized by a triad of:
- Flaccid iris stroma that billows in response to intraocular fluid currents.
- Tendency of the iris to prolapse toward incisions.
- Progressive intraoperative miosis despite preoperative dilation
The primary risk factor for IFIS is the use of alpha-1 adrenergic antagonists, especially tamsulosin, which the patient was taking for benign prostatic hyperplasia (BPH). These medications selectively block alpha-1A receptors found in the iris dilator muscle, resulting in poor dilation and intraoperative instability.
In 2004, awareness of this association was lacking. Since the recognition of IFIS, it has become standard practice to ask cataract patients about their history of alpha-blocker use. Surgical approaches have also evolved, including the use of intracameral phenylephrine, pupil expansion devices, and advanced viscoelastic techniques.
KEY LEARNING POINTS:
RECOMMENDATIONS:
When performing cataract surgery on a patient who has taken Flomax (tamsulosin) – even if they stopped it months or years ago – it’s critical to anticipate and manage Intraoperative Floppy Iris Syndrome (IFIS). Here are some surgical pearls to help:
PREOPERATIVE PLANNING:
- Identify Flomax Use Early: Ask about current and past alpha-blocker use (even if discontinued long ago). Document and notify your surgical team—anesthesia and scrub staff included.
- Counsel the Patient: Discuss the increased complexity of the surgery and possible complications (e.g., iris damage, longer surgery, need for additional tools).
INTRAOPERATIVE TECHNIQUES:
1. Use Intracameral Phenylephrine and/or Epinephrine:
- Helps stiffen the iris and reduce billowing.
- Common mix: phenylephrine 1.5% + lidocaine 1% intracamerally (pre-mixed options like Shugarcaine or Mydrane in some countries).
2. Low Flow and Low Pressure:
- Minimize fluid turbulence with low phaco settings.
- Avoid over-inflating the anterior chamber.
3. Mechanical Pupil Expansion:
- Be prepared to use iris hooks or pupil expansion rings (e.g., Malyugin Ring).
- The Malyugin Ring is especially helpful if the pupil is moderately dilated but the iris is floppy.
4. Viscomydriasis:
- Use dispersive viscoelastic (e.g., Healon5 or Viscoat) to mechanically maintain iris position and pupil size.
5. Gentle Manipulation:
- Avoid touching the iris; even minimal trauma can cause prolapse.
- Plan for longer surgery time—work carefully and patiently.
POSTOPERATIVE CARE:
- Monitor for iris trauma, pupil abnormalities, or inflammation.
- Follow typical cataract post-op regimens but consider extended steroid drops if there was significant iris manipulation.
CONCLUSION:
This case underscores the importance of comprehensive preoperative assessment, including medication history, especially in male patients with BPH. It also illustrates how evolving clinical knowledge can shed light on previously unexplained surgical complications.
