IFIS – Intraoperative IFIS – Intraoperative Floppy-Iris SyndromeFloppy-Iris Syndrome

Fritz AllenFritz Allen

10-201010-2010

IFISIFIS

Some slides were borrowed from Some slides were borrowed from David Chang with his permissionDavid Chang with his permission

ASCRS ASCRS

White Paper White Paper JCRS 12/08 JCRS 12/08

IFISIFIS

Poor pupil dilation Poor pupil dilation Triad of (1) Billowing of a flaccid Iris Triad of (1) Billowing of a flaccid Iris

stroma (2) propensity for iris stroma (2) propensity for iris prolapse toward the phaco and side prolapse toward the phaco and side port incisions (3) progressive port incisions (3) progressive intraoperative pupil constrictionintraoperative pupil constriction

First described 2005 by Chang and First described 2005 by Chang and CampbellCampbell

Can be mild, moderate or severeCan be mild, moderate or severe

IFIS-Surgical ComplicationsIFIS-Surgical Complications

Iris TraumaIris Trauma Vitreous loss – one retrospective Vitreous loss – one retrospective

study as high as 70%)study as high as 70%) Dropped lensDropped lens Retained cortexRetained cortex Dislocated iolDislocated iol Macular edemaMacular edema Decreased post op visionDecreased post op vision

Email from 5/5/09 Dear Perry,   I regret to inform that I had another complication with

another FLOMAX case yesterday.   While I used intracameral epi, iris hooks, and had great visualization, I still managed to break capsule leave cortex, drop some nucleus.

  Then, shaken by the first case, I dropped a nucleus in my

2nd case of six yesterday.   My confidence is at an ebb.    I'm thinking  of punting complicated cases for awhile, until i

feel more confident.

IFISIFIS

No correlation between IFIS and eye No correlation between IFIS and eye color, diabetes , or pseudoexfoliationcolor, diabetes , or pseudoexfoliation

Seemed to be related to Flomax and Seemed to be related to Flomax and BPH patients. BPH patients.

BPH- Benign Prostatic Hyperplasia BPH- Benign Prostatic Hyperplasia IncidenceIncidence

50% of men older than 5050% of men older than 50 90% of men older than 8590% of men older than 85 Patients have trouble with bladder Patients have trouble with bladder

emptying and urinary frequencyemptying and urinary frequency

Tamsulosin (Flomax) Tamsulosin (Flomax)

The most commonly prescribed drug The most commonly prescribed drug for treatment of lower urinary tract for treatment of lower urinary tract symptoms of benign prostatic symptoms of benign prostatic hyperplasia (BPH)- also used short-term hyperplasia (BPH)- also used short-term for renal calculifor renal calculi

relaxes smooth muscle in the prostate relaxes smooth muscle in the prostate and bladder neckand bladder neck

Improves bladder emptying and Improves bladder emptying and reduces urinary frequencyreduces urinary frequency

Systemic alpha 1 adrenergic antagonistSystemic alpha 1 adrenergic antagonist

Alpha 1 antagonistsAlpha 1 antagonists

Because vascular smooth muscle is Because vascular smooth muscle is mediated by alpha 1 receptors they can be mediated by alpha 1 receptors they can be used for hypertension. Postural used for hypertension. Postural hypotension can be a problemhypotension can be a problem

Terazosin (Hytrin)Terazosin (Hytrin) Doxazosin (Cardura)Doxazosin (Cardura) Alfuzosin (Uroxatral) - non subtype Alfuzosin (Uroxatral) - non subtype

selectiveselective Silodosin (Rapaflo) selective alpha 1ASilodosin (Rapaflo) selective alpha 1A

IFISIFIS

There are at least 3 human alpha 1 There are at least 3 human alpha 1 receptor subtypes-1A, 1B, and 1Dreceptor subtypes-1A, 1B, and 1D

Tamsulosin has a 20 fold greater Tamsulosin has a 20 fold greater affinity for 1A than 1D which affinity for 1A than 1D which accounts for it being more accounts for it being more uroselective and with fewer uroselective and with fewer cardiovascular side effectscardiovascular side effects

IFISIFIS

Incidence one prospective study of Incidence one prospective study of 1298 cases showed tamsulosin 1298 cases showed tamsulosin accounted for only 26% of alpha 1 accounted for only 26% of alpha 1 antagonists but for 71% all iris antagonists but for 71% all iris prolapseprolapse

The Effect of the The Effect of the αα11--Adrenergic Receptor Adrenergic Receptor

Antagonist Antagonist Tamsulosin Tamsulosin (Flomax) on Iris Dilator (Flomax) on Iris Dilator

Muscle AnatomyMuscle Anatomy

Ricardo Santaella, MD, John Destafeno, Ricardo Santaella, MD, John Destafeno, MD, Sara Miller, PhD, Sandra Stinnett, MD, Sara Miller, PhD, Sandra Stinnett, DrPH, Alan Proia, MD, Terry Kim, MDDrPH, Alan Proia, MD, Terry Kim, MD

Albert Eye Research InstituteAlbert Eye Research InstituteDuke University Medical CenterDuke University Medical Center

Durham, North CarolinaDurham, North Carolina

Mean Mean (micrometers)(micrometers)

Tamsulosin Tamsulosin group n=26 group n=26

Control Control Group n=26 Group n=26

P-P-ValueValue

**

Iris Dilator Iris Dilator Muscle Muscle

ThicknessThickness

6.62 6.62 (SD=2.22)(SD=2.22)

8.208.20 (SD=1.77)(SD=1.77)

0.0040.004

Iris Stromal Iris Stromal ThicknessThickness

275.98 275.98 (SD=68.17)(SD=68.17)

274.65 274.65 (SD=57.96)(SD=57.96) 0.9250.925

Control SubjectTamsulosin Subject

Light Microscopy Morphometric Results

Representative sample photomicrographs * Indicates iris dilator smooth muscle. (H&E)

Other BPH drugsOther BPH drugs FinasterideFinasteride Dutasteride (Avodart)Dutasteride (Avodart) These are 5 alpha reductase inhibitiors These are 5 alpha reductase inhibitiors

and lower the level of the hormone and lower the level of the hormone dihydrotestosterone with reduction in dihydrotestosterone with reduction in prostate size over time and do not have prostate size over time and do not have associated IFISassociated IFIS

Prostate Cancer Prevention Trial –NCI Prostate Cancer Prevention Trial –NCI sponsored with 18000 men found sponsored with 18000 men found finasteride reduces risk of prostate cancer finasteride reduces risk of prostate cancer by about 25% in men 55 and older by about 25% in men 55 and older

IFIS Management IFIS Management StrategiesStrategies

Severity determines approach – Severity determines approach – unfortunately there is no reliable way to unfortunately there is no reliable way to predict severity in advance of surgerypredict severity in advance of surgery

PharmacologicPharmacologic Microincisional approachesMicroincisional approaches Highly viscous or viscoadaptive ophthalmic Highly viscous or viscoadaptive ophthalmic

viscosurgical devices (OVD)viscosurgical devices (OVD) Low flow fluid parametersLow flow fluid parameters Mechanical dilating devices – hooks and Mechanical dilating devices – hooks and

ringsrings

IFISIFIS

Partial thickness sphincterotomies Partial thickness sphincterotomies and mechanical pupil stretching are and mechanical pupil stretching are ineffective and may make it worseineffective and may make it worse

PharmacologicPharmacologic Serum half-life is 2-3 daysSerum half-life is 2-3 days Stopping Flomax – benefit unproven - the effect Stopping Flomax – benefit unproven - the effect

can last yearscan last years Intercameral injection of alpha 1 agonists – ie Intercameral injection of alpha 1 agonists – ie

phenylephrine –can help with dilation and phenylephrine –can help with dilation and increase iris rigidity by increasing smooth muscle increase iris rigidity by increasing smooth muscle tone- Joel Shugar’s epi-Shugarcaine mixture (has tone- Joel Shugar’s epi-Shugarcaine mixture (has greater effect if neo is not used preopgreater effect if neo is not used preop

Topical atropine 1% tid for 1-3 days preop:good Topical atropine 1% tid for 1-3 days preop:good preop dilation but not as good controlling size preop dilation but not as good controlling size intraop – could cause urinary retention – do not intraop – could cause urinary retention – do not stop flomax if using atropinestop flomax if using atropine

Intraoperative TechniquesIntraoperative Techniques

Well constructed woundWell constructed wound Trypan blue-to visualize the capsule Trypan blue-to visualize the capsule

during phacoduring phaco Low fluidics-lower bottle, lower Low fluidics-lower bottle, lower

aspiration(eg<25cc/min) and aspiration(eg<25cc/min) and vacuum (<200mm HG)vacuum (<200mm HG)

Use of viscoelastics – eg Healon 5Use of viscoelastics – eg Healon 5

Mechanical Pupil Expansion Mechanical Pupil Expansion DevicesDevices

Iris retractors-6-0 or 4-0 in a Iris retractors-6-0 or 4-0 in a diamond pattern with one diamond pattern with one subincisionallysubincisionally

Rings such as the Malyugin ringRings such as the Malyugin ring

IFIS IFIS

Combination of approaches Combination of approaches depending on how severe.depending on how severe.

ASCRS IFIS Survey 3/08ASCRS IFIS Survey 3/08Chang DF, et al; Cataract Clinical Committee Chang DF, et al; Cataract Clinical Committee J Cataract Refract Surg (July) 2008; 34: 1201-1209J Cataract Refract Surg (July) 2008; 34: 1201-1209

957 respondents957 respondents•75% US75% US

42%42% ((>>2 cases/mo) 2 cases/mo) 23%23% ((>3>3 cases/mo) cases/mo)

IFIS - 2009 IFIS - 2009 Unanswered ?’sUnanswered ?’s

Tamsulosin vs non-selective Tamsulosin vs non-selective αα-blockers-blockers Stop Stop αα-blockers preop? -blockers preop? Best surgical strategy?Best surgical strategy? Complication rate now?Complication rate now? Should patients see EyeMDShould patients see EyeMD

before starting before starting αα-blockers? -blockers?

epi

hooks

H 5

atropine

MultiplestrategiesRings

Other

Favorite Favorite initial initial

strategy strategy for IFISfor IFIS

18% more difficult,same risk

65% more difficult, >risk

5% “No different”

Surgical difficulty with tamsulosin

13% very difficult, >risk

95% “More Difficult”

5%

77% “Greater Risk”

23% 23% >PC Rupture>PC Rupture

52% 52% > iris trauma> iris trauma

30%

Would you take tamsulosin ? Would you take tamsulosin ? (mild cataract)(mild cataract)

36% 36% “yes”“yes”

24%24% “cataract surgery 1st” “cataract surgery 1st” 17%17% “take nonselective “take nonselective αα-blocker” -blocker” 23% 23% “avoid all “avoid all αα-blockers” -blockers”

What do Ophthalmologists really think?

Surveys tend to bring out the macho and tend to go to high volume surgeons

55yo ophthalmologist in Kaiser NW recently had a kidney stone. Went to ER diagnosed and offered pain meds and Flomax – he refused the flomax even for one dose

Routine referral pre-tamsulosin?

41% “NO”

38% “IF HX

OR CATARACT”

21% “ROUTINELY”

VA

OtherOther αα-blockers-blockers 58% “NO”

11% “ROUTINELY”31% “IF HX CAT”

More education for prescribing MD?

91% Agree

3% Disagree

Prescribing MD EducationPrescribing MD Education

Sallam A, letter JCRS 6-08Sallam A, letter JCRS 6-08

• survey 85 PCPs (UK)survey 85 PCPs (UK) • 97% (62/64) unaware of IFIS97% (62/64) unaware of IFIS• 80% > 5 tamsulosin Rx /mo80% > 5 tamsulosin Rx /mo

MAS Ophthalmology Experience MAS Ophthalmology Experience

IFIS is real. IFIS is real. Increased complications are Increased complications are

encountered when we operate on these encountered when we operate on these patients.patients.

Multiple strategies are used adding Multiple strategies are used adding time, material expenses, surgeon stress.time, material expenses, surgeon stress.

Scheduling adds 15 minutes to a cases Scheduling adds 15 minutes to a cases for some surgeons. A ring is $100, for some surgeons. A ring is $100, hooks $24, viscoadaptives $50hooks $24, viscoadaptives $50

MAS MAS

Terazosin (Hytrin) is the Kaiser first Terazosin (Hytrin) is the Kaiser first line alpha blockerline alpha blocker

Tamsulosin (Flomax) is second line Tamsulosin (Flomax) is second line but on the formularybut on the formulary

Flomax is used a lot because it has Flomax is used a lot because it has less orthostatic changes and does less orthostatic changes and does not require titration of dose.not require titration of dose.

Ophthalmology and Urology Ophthalmology and Urology Working TogetherWorking Together

Education of providers Education of providers Discuss cataracts with patients and Discuss cataracts with patients and

look at their eye notes in HC look at their eye notes in HC Use non selective alpha one Use non selective alpha one

antagonistsantagonists Standardize orders for titration of Standardize orders for titration of

hytrinhytrin