IFIS and Cataract Surgery
IFIS and Cataract Surgery
Tamsulosin has been used as an agent to improve urinary symptoms, often in men with an enlarged prostate. It acts as an alpha-1 antagonist and inhibits smooth muscle contraction within the urinary bladder and prostate. Intraoperative floppy iris syndrome (IFIS), a side effect of tamsulosin, was noted in 2005. This syndrome is characterized by poor pupillary dilation, prolapse of the iris, intraoperative billowing of the iris, and progressive pupillary miosis. Inhibition and atrophy of the iris dilator muscle may be responsible for these perioperative findings, although histologic confirmation is lacking.
Intraoperative complications have been noted as a result of IFIS, including iris trauma with sequent atrophy and rupture of the posterior capsule with vitreous loss. Furthermore, commonly used techniques for cataract surgery in patients with small pupils have largely been ineffective in patients with IFIS.
Prospective Multicenter Evaluation of Cataract Surgery in Patients Taking Tamsulosin (Flomax)
Chang DF, Osher RH, Wang L, Koch DD
Ophthalmology. 2007;114:957-964
The authors of this prospective observational case series reviewed 135 men (167 eyes) who had a history of tamsulosin use and underwent phacoemulsification. The severity of IFIS was noted as mild in 17%, moderate in 30%, and severe in 43% of patients (no IFIS was noted in 10%). One of 4 techniques was used in the management of IFIS: preoperative topical 1% atropine, iris retractors, pupil expansion ring, and the use of a viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters. The choice was left up to the operating surgeon, and some used more than one technique. When iris retractors or pupil expansion rings were used, no other method proved necessary. Topical atropine was used as the sole method for 8 eyes, and in 11 others additional techniques were used. Using these techniques, the rate of posterior capsule rupture and vitreous loss was 0.6% (1 in 167 eyes). Tamsulosin was discontinued (1-8 weeks preoperatively) for 32 eyes, and no significant difference was seen in IFIS severity.
The complications of IFIS have sparked changes in the perioperative management of patients undergoing cataract surgery. These intraoperative findings have also prompted mention of an adverse ocular event in those considering cataract surgery in recent television advertisements for tamsulosin. The authors pointed out that IFIS is not specific to tamsulosin and may occur with other alpha-1 antagonists, although it appears to be less severe. It is not clear when in the course of therapy with an alpha-1 antagonist that a patient may be at risk for IFIS, but some reports suggest that this syndrome may occur within weeks of starting tamsulosin.
The findings of this study emphasize both the importance of obtaining a history of tamsulosin use (including prior use -- IFIS has been reported years after discontinuation of tamsulosin) and of experienced surgeons. IFIS was anticipated in this study, and these patients did well, with a lower complication rate than that reported in prior series of patients using tamsulosin whose IFIS was not necessarily suspected. Moreover, the 10 centers involved in this study had 15 experienced cataract surgeons who would have a very low expected rate of intraoperative complications. It is not clear whether IFIS would be managed as well in the hands of less experienced surgeons.
Tamsulosin has been used as an agent to improve urinary symptoms, often in men with an enlarged prostate. It acts as an alpha-1 antagonist and inhibits smooth muscle contraction within the urinary bladder and prostate. Intraoperative floppy iris syndrome (IFIS), a side effect of tamsulosin, was noted in 2005. This syndrome is characterized by poor pupillary dilation, prolapse of the iris, intraoperative billowing of the iris, and progressive pupillary miosis. Inhibition and atrophy of the iris dilator muscle may be responsible for these perioperative findings, although histologic confirmation is lacking.
Intraoperative complications have been noted as a result of IFIS, including iris trauma with sequent atrophy and rupture of the posterior capsule with vitreous loss. Furthermore, commonly used techniques for cataract surgery in patients with small pupils have largely been ineffective in patients with IFIS.
Prospective Multicenter Evaluation of Cataract Surgery in Patients Taking Tamsulosin (Flomax)
Chang DF, Osher RH, Wang L, Koch DD
Ophthalmology. 2007;114:957-964
The authors of this prospective observational case series reviewed 135 men (167 eyes) who had a history of tamsulosin use and underwent phacoemulsification. The severity of IFIS was noted as mild in 17%, moderate in 30%, and severe in 43% of patients (no IFIS was noted in 10%). One of 4 techniques was used in the management of IFIS: preoperative topical 1% atropine, iris retractors, pupil expansion ring, and the use of a viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters. The choice was left up to the operating surgeon, and some used more than one technique. When iris retractors or pupil expansion rings were used, no other method proved necessary. Topical atropine was used as the sole method for 8 eyes, and in 11 others additional techniques were used. Using these techniques, the rate of posterior capsule rupture and vitreous loss was 0.6% (1 in 167 eyes). Tamsulosin was discontinued (1-8 weeks preoperatively) for 32 eyes, and no significant difference was seen in IFIS severity.
The complications of IFIS have sparked changes in the perioperative management of patients undergoing cataract surgery. These intraoperative findings have also prompted mention of an adverse ocular event in those considering cataract surgery in recent television advertisements for tamsulosin. The authors pointed out that IFIS is not specific to tamsulosin and may occur with other alpha-1 antagonists, although it appears to be less severe. It is not clear when in the course of therapy with an alpha-1 antagonist that a patient may be at risk for IFIS, but some reports suggest that this syndrome may occur within weeks of starting tamsulosin.
The findings of this study emphasize both the importance of obtaining a history of tamsulosin use (including prior use -- IFIS has been reported years after discontinuation of tamsulosin) and of experienced surgeons. IFIS was anticipated in this study, and these patients did well, with a lower complication rate than that reported in prior series of patients using tamsulosin whose IFIS was not necessarily suspected. Moreover, the 10 centers involved in this study had 15 experienced cataract surgeons who would have a very low expected rate of intraoperative complications. It is not clear whether IFIS would be managed as well in the hands of less experienced surgeons.
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