EyeWorld Asia-Pacific March 2020 Issue

26 EWAP MARCH 2020 SECONDARY FEATURE usually use epinephrine in the bottle and inject phenylephrine into the anterior chamber to try to improve stability of the iris if I am concerned. You can use a dispersive viscoelastic to try to hold the iris in position early in the case, but eventually that OVD is going to have to be removed. I do not use the brand name phenylephrine-ketorolac. I don’t think the cost-benefit is there when we get intracameral phenylephrine for such a low price at our surgery center.” “I find that use of a concentration of epi [epinephrine] in the anterior chamber at the beginning of surgery can be very helpful to prevent IFIS in patients on alpha blockers,” Dr. Safran wrote. “Others use intraoperative phenylephrine either compounded or in commercial product Omidria [Omeros]. When I personally compared Omidria to strong epi (1 ampule mixed with 4 cc BSS) in my hands epi was far superior to Omidria.” Going into further detail, Dr. Myers wrote: “Prophylactic intraocular adrenergic agents, such as epinephrine buffered to neutral pH as in epi- Shugarcaine, will ameliorate the symptoms. In fact, those surgeons who routinely dilated patients with intracameral adrenergic agents and lidocaine did not see IFIS at all. Rarely, reduction of pupil size that was gradual and controlled occurred, but no iris billowing nor rapid miosis. This is a case of having a cure for a disease before the disease existed. Atropine has been suggested as well, but it risks inducing urinary blockage. Topical agents are ineffective. Omidria is an FDA approved irrigation medication with some evidence for reduction in IFIS signs, but with a much lower concentration of phenylephrine and a much greater cost.” Intraop management Medical intervention can be enough to deal with IFIS. “Pharmacologic management of IFIS has been satisfactory without typically resorting to more expensive devices,” Dr. Myers wrote. However, “[i]f the pupil size is inadequate to complete a capsulorhexis after the intracameral dilation agents and OVD are instilled, then I proceed to using either hooks or less commonly rings,” he added. “The decision is based on the pupil size and not the potential for IFIS developing. It is better to place hooks or rings prior to capsulorhexis to avoid damage to the capsule.” “Iris retractors are my choice for patients where the pupil dilates poorly and the patient is on alpha blockers,” Dr. Safran wrote. “They are very safe and work extremely well.” Surgeons should use iris dilating devices with caution. “Any time you are using a device to manipulate the iris, there is a risk of causing an irregular pupil, iridodialysis, or bleeding,” Dr. Lee wrote. “However, these are rare problems, and most cataract surgeons are very familiar with using mechanical dilation.”  Although other devices such as the Malyugin ring work well, Dr. Lee prefers reusable hooks because they allow the surgeon to stretch the iris out more to get it out of the way, which IFIS irises tolerate well. Hooks can be left in later to verify toric IOL position at the end of the case, and take up less space in a shallow chamber. Nevertheless, he will prefer a ring in certain cases, such as small lid fissures, uncooperative patients, or keratoconus.  Usual and unusual suspects Among the alpha-1 adrenergic antagonists, “tamsulosin and silodosin are the two most likely to cause significant IFIS,” probably due to their being selective alpha blockers, Dr. Lee wrote. “It’s important to remember that tamsulosin is also in a combination with dutasteride called Jalyn and that women are now taking tamsulosin more frequently.” However, it’s just as important to remember that alpha blockers aren’t the only possible causes of IFIS. “Tamsulosin is the agent most associated with IFIS, but other causes are anything that might affect the iris dilator muscle, including other alpha blockers, diabetes, and certain viral infections,” Dr. Myers wrote. “For this reason, I use intracameral dilation with phenylephrine and lidocaine on every patient, regardless of their use of alpha blockers systemically.” Dr. Safran also added that over-the-counter saw palmetto has been shown to cause IFIS. This is important to ask for in men (and some women) who might be using it and not mention it. EWAP References 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg . 2005 Apr;31(4):664–673. 2. Santaella RM, et al. The effect of a 1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth muscle anatomy. Ophthalmology . 2010;117:1743–1749. Editors’ note: Dr. Lee is affiliated Altos Eye Physicians, Los Altos, California, and declared no relevant financial interests. Dr. Myers is affiliated with Myers Center for the Eye, Skokie, Illinois, and has relevant financial interests with Leiters. Dr. Safran practices in Lawrenceville, New Jersey, and declared no relevant financial interests. The IOL has dislocated into the back of the eye and is sitting on the retina. One haptic appears to be kinkied. Same patient as in the prior two photos at 1 week after pars plana vitrectomy, exchange of damaged IOL for sutured PCIOL, and iris repair. Source (all): Steven Safran, MD