Intraoperative floppy iris syndrome and prevalence of intraoperative complications
Reviewed by Efrosini Papagiannuli

Alpha-blockers (particularly of the selective type) are known to be associated with intraoperative floppy iris (IFIS) and poor dilation, which can present in various severities during cataract surgery and need to be recognised in order to avoid intraoperative complications. Methods used to overcome these include the use of Healon 5, iris retractors, pupil expansion rings and topical atropine. In this multicentre, retrospective study the authors assessed the prevalence of untoward events during cataract surgery in patients with IFIS and / or the use of pupillary expansion devices. Data from 4923 eyes were collected looking at the use of a-blockers, IFIS and complications like iris trauma, iris prolapse, posterior or anterior capsular tear, intraoperative vitreous prolapse and the use of pupillary expansion devices. A total of 1254 eyes (25.5%) were on alpha-blockers preoperatively and of these, 428 eyes (34.1%) had IFIS. Of the remaining 3663 eyes not on alpha-blockers, 141 eyes developed IFIS, bringing the total IFIS eyes to 569. Therefore 75.2% (428/569) of IFIS eyes were on alpha-blockers perioperatively. It is interesting to note that a large proportion of IFIS eyes were on non-selective alpha-blockers (188/627 eyes versus 229/587 eyes on selective alpha-blockers and 11/40 eyes on both). Of the IFIS eyes (569) 21.97% developed intraoperative complications, with 15.1% having one complication and 7% developing more than one complication. The corresponding figures of non-IFIS eyes were 7.6% total complications, with 4.5% having one complication and 3% more than one complication. A total of 430/4923 eyes (8.7%) had a pupillary expansion device used during surgery, of which 186 eyes (43.3%) had IFIS. Interestingly pupillary expansion devices were used in eyes on selective alpha-blockers 2.5 times more often than in IFIS eyes on non-selective alpha-blockers. The authors conclude that patients on alpha-blockers are at increased risk of IFIS, however, they also demonstrated that non-selective alpha-blockers contribute to a much higher rate of IFIS (43.9%) than previously reported. They are aware of the study limitations secondary to selection bias (predominantly male patients), its retrospective nature, some missing data and possible mis-classifications / under-reporting due to the lack of a standard definition for IFIS. Another limiting factor that is pointed out is that only mechanical pupillary expansion devices were captured and therefore pharmacological means of pupillary expansion may have been missed out, which in part may explain the low utilisation.

Intraoperative floppy iris syndrome and prevalence of intraoperative complications: results from ophthalmic surgery outcomes database.
Vollman DE, Gonzalez-Gonzalez LA, Chomsky A, et al.
AMERICAN JOURNAL OF OPHTHALMOLOGY
2014;157:1130-5.