What is the recommended management for a patient diagnosed with Intraoperative Floppy Iris Syndrome (IOFIS) with anticipated iris prolapse?

Management of Intraoperative Floppy Iris Syndrome (IFIS) with Anticipated Iris Prolapse

When IFIS with anticipated iris prolapse is diagnosed preoperatively, implement mechanical iris stabilization with iris retractors or pupil expansion devices, combined with high-viscosity ophthalmic viscosurgical devices (OVDs) to maintain anterior chamber depth and prevent iris billowing during phacoemulsification. 1, 2

Preoperative Preparation

Patient Identification and Risk Assessment

• Identify patients on alpha-1 adrenergic receptor antagonists (especially tamsulosin) as high-risk for IFIS, as this medication class is the primary causative agent 1, 3
• Document history of benign prostatic hyperplasia medications, including 5α-reductase inhibitors and other alpha-blockers, which increase IFIS risk 2
• Note that IFIS can occur even after discontinuation of these medications, so stopping them preoperatively does not eliminate risk 1, 4

Preoperative Pharmacologic Measures

• Consider preoperative atropine or other mydriatics to achieve maximum pupil dilation before surgery 4
• Avoid relying solely on standard preoperative dilation protocols, as progressive miosis is a hallmark of IFIS 1, 2

Intraoperative Management Strategies

Mechanical Iris Stabilization (Primary Approach)

• Use iris retractors or pupil expansion devices (such as Malyugin ring) as the primary mechanical intervention to prevent iris prolapse and maintain adequate pupil size throughout the procedure 2, 5
• If iris prolapse occurs despite preventive measures, immediately place a single subincisional iris retractor after repositioning the prolapsed iris—this is the most successful approach for managing active prolapse 5
• Deploy multiple iris hooks (typically 4) at the pupil margin if diffuse iris billowing threatens surgical visualization 2, 4

Viscoelastic Management

• Use high-viscosity cohesive OVDs liberally to maintain anterior chamber depth and tamponade the floppy iris against the posterior capsule 2, 4
• Refill the anterior chamber frequently with OVD to prevent iris billowing and prolapse toward incision sites 4

Surgical Technique Modifications

• Create smaller incisions (2.2-2.4mm) to reduce the risk of iris prolapse through surgical wounds 2, 4
• Lower phacoemulsification flow rates and vacuum settings to minimize anterior chamber turbulence that exacerbates iris movement 2, 4
• Maintain continuous anterior chamber pressurization throughout the procedure 4

Postoperative Monitoring

Immediate Postoperative Period

• Check intraocular pressure (IOP) within 30 minutes to 2 hours following surgery, as IOP elevation can occur from retained viscoelastic or inflammation 6
• Monitor for iris trauma, posterior capsule rupture, and vitreous loss—complications that are significantly increased with IFIS 2

Follow-up Assessments

• Examine for corneal endothelial damage, which occurs more frequently in IFIS cases due to increased surgical manipulation 2
• Assess for secondary angle closure or peripheral anterior synechiae formation using gonioscopy if IOP elevation develops 7, 6
• Monitor for persistent inflammation requiring extended topical corticosteroid therapy 6

Critical Clinical Pearls

Communication and Documentation

• Ophthalmologists must obtain detailed medication history including all alpha-blockers, as non-selective agents also cause IFIS (though less frequently than tamsulosin) 1, 3
• Urologists initiating alpha-blocker therapy should inform patients about potential cataract surgery complications and recommend ophthalmology consultation before starting these medications 3

Outcome Expectations

• With appropriate preoperative identification and intraoperative precautions, surgical outcomes and visual acuity results are excellent and similar to non-IFIS eyes 1
• The key to success is anticipation—unrecognized IFIS leads to significantly higher complication rates including corneal damage, iris trauma, capsular rupture, and vitreous loss 2