From the Guidelines
IFIS syndrome is a significant complication during cataract surgery, primarily associated with the use of alpha-1 adrenergic receptor antagonists, and patients should be informed of the associated risks and advised to discuss these risks with their ophthalmologists before initiating alpha blocker therapy, as recommended by the 2023 European Association of Urology guidelines 1. When managing patients with IFIS syndrome, it is crucial to identify at-risk patients before surgery by taking a thorough medication history, as the effect can persist even years after discontinuation of the medication.
- Surgical strategies for managing IFIS syndrome include:
- Using iris hooks or pupil expansion devices
- Employing viscoadaptive ophthalmic viscoelastic devices
- Creating smaller incisions
- Using intracameral phenylephrine or epinephrine
- Preoperative atropine drops may also help According to a recent guideline, urologists initiating alpha blocker therapy should inquire about plans for future cataract surgery and inform them of IFIS risk, with delay of medication initiation until after planned procedures 1.
- The syndrome occurs because alpha-1 antagonists block receptors in the iris dilator muscle, preventing normal pupillary dilation and causing the iris to become floppy during surgery when irrigation fluid flows through the anterior chamber. It is essential to note that increased awareness of IFIS has resulted in a year-by-year decreased complication rate, as reported in recent studies 1.
- Ophthalmologists should be informed about alpha-blocker use before surgery, as IFIS increases the risk of complications including posterior capsule rupture, vitreous loss, and iris trauma.
From the FDA Drug Label
5.5 Intraoperative Floppy Iris Syndrome Intraoperative Floppy Iris Syndrome (IFIS) has been observed during cataract and glaucoma surgery in some patients on or previously treated with alpha 1 blockers, including Tamsulosin Hydrochloride Capsules [ see Adverse Reactions (6. 2) ]. Most reports were in patients taking the alpha 1 blocker when IFIS occurred, but in some cases, the alpha 1blocker had been stopped prior to surgery. In most of these cases, the alpha 1 blocker had been stopped recently prior to surgery (2 to 14 days), but in a few cases, IFIS was reported after the patient had been off the alpha 1 blocker for a longer period (5 weeks to 9 months) IFIS is a variant of small pupil syndrome and is characterized by the combination of a flaccid iris that billows in response to intraoperative irrigation currents, progressive intraoperative miosis despite preoperative dilation with standard mydriatic drugs and potential prolapse of the iris toward the phacoemulsification incisions The patient's ophthalmologist should be prepared for possible modifications to their surgical technique, such as the utilization of iris hooks, iris dilator rings, or viscoelastic substances. IFIS may increase the risk of eye complications during and after the operation. The benefit of stopping alpha 1blocker therapy prior to cataract or glaucoma surgery has not been established The initiation of therapy with tamsulosin in patients for whom cataract or glaucoma surgery is scheduled is not recommended.
IFIS Syndrome is a risk associated with the use of tamsulosin, particularly in patients undergoing cataract or glaucoma surgery.
- The syndrome is characterized by a flaccid iris that billows in response to intraoperative irrigation currents, progressive intraoperative miosis, and potential prolapse of the iris.
- The risk of IFIS may be increased in patients taking alpha 1 blockers, including tamsulosin, even if the medication has been stopped prior to surgery.
- Ophthalmologists should be prepared for possible modifications to their surgical technique to manage IFIS.
- The benefit of stopping alpha 1 blocker therapy prior to surgery has not been established, and the initiation of tamsulosin therapy is not recommended in patients scheduled for cataract or glaucoma surgery 2.