13 EyeWorld Asia-Pacific | September 2024 by Ishtiaque Anwar, MD Taming The Floppy Iris – Sleeve Hydrodissection! Intraoperative Floppy Iris Syndrome (IFIS) was first described by David F Chang and John R. Campbell in 2005. IFIS poses unique challenges for cataract surgeons, characterized by a triad of flaccid iris stroma, propensity for iris to prolapse towards surgical wounds and progressive intraoperative pupillary constriction. (Chang & Campbell, 2005) Iris dilator pupillae muscles contain α1-adrenergic receptors which contract with dilating drugs facilitating safe and smooth cataract surgery. α1-adrenergic receptor-blocking drugs such as Tamsulosin block dilator muscle contraction, which causes poor pupillary dilation and sometimes severe loss of pupillary tone. David F Chang identified Tamsulosin as the drug related to IFIS but over the years IFIS has been correlated with several risk factors including: age, gender, hypertension, diabetes, other α1- adrenergic receptor antagonists (α1-ARAs), 5-α reductase inhibitor such as finasteride, angiotensin II receptor inhibitors, benzodiazepines, antipsychotics, antidepressants, antihypertensive drugs, preoperatively decreased dilated pupil diameter, acute primary angle closure, which are thought to cause loss of iris tone, and iris prolapse during cataract surgery (Kumar & Raj, 2021). Iris prolapse can occur at any stage and is sometimes encountered even after creating a well-constructed multiplanar clear corneal incision. Hydrodissection is the most common step when iris prolapse occurs. But hydrodissection is a crucial step for rotating the nucleus effectively and safely, and is particularly pivotal in IFIS cases where visualization is compromised due to poor pupil dilatation. Once an iris is prolapsed, its tissue becomes more flaccid, which can lead to further prolapse. Extensive prolapse can lead to complications such as iris dialysis, tissue loss, and bleeding. Iris prolapse may lead to complications secondary to miosis such as iris trauma/chafing, posterior capsular rupture, loss of vitreous, nuclear drop, cystoid macular edema and exaggerated and prolonged postoperative inflammation (Kumar & Raj, 2021). Most of the time, using iris hooks to dilate these poorly dilated pupils in IFIS patients can help to prevent iris prolapse. However, there are instances when an iris prolapses even after using iris hooks or pupil dilating devices during hydrodissection (Figure 1). Iris prolapse in IFIS occurs because irrigating fluid is entrapped below the poorly dilated iris (pupil), with only main incision and side port openings as places for fluid to escape. At this time, the trapped fluid pushes the flaccid iris above the incisions, causing iris prolapse (Figure 2). If we could tamponade the iris near the main wound during hydro dissection, this prevents fluid accumulation and creates a passage for the hydro fluid to escape, preventing iris prolapse and decreasing the chance of further prolapse, so as to allow a completed surgery without grave complications and consequences. Hence, I propose sleeve hydro dissection, which passes the hydro dissection cannula in the commercially available phaco sleeve (Figure 3). The sleeve is then introduced with canula in the eye through the main incision (Figure 4) to tamponade the iris before hydro dissection (single or multi quadrant) (Figure 5). This prevents iris prolapse as 1) the wound is sealed by the sleeve 2) the sleeve tamponades the iris near the wound and 3) the hydro fluid comes out through an alternative channel between the sleeve and cannula continuously (Figure 6-7). When in place, the sleeve prevents the chance of fluid accumulation in the eye during hydro dissection. I have measured the pupil size with a digital callisto system from Zeiss Meditec, Germany before and after the sleeve hydro procedure and there was no reduction of pupil size after this procedure (Figure 8). With over a hundred cases of IFIS performed over the last three years that I have been doing Sleeve Hydrodissection, I have not seen any iris prolapse issues since. The introduction of sleeve hydrodissection offers a promising technique for safe phaco surgery in IFIS cases, alleviating one of the significant challenges surgeons face in managing these complex scenarios. Reference: 1. Chang, D. F., & Campbell, J. R. (2005). Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract and Refractive Surgery, 31(4), 664–673. https://doi.org/10.1016/j.jcrs.2005.02.027 2. Kumar, A., & Raj, A. (2021). Intraoperative floppy iris syndrome: an updated review of literature. In International Ophthalmology (Vol. 41, Issue 10, pp. 3539–3546). Springer Science and Business Media B.V. https://doi.org/10.1007/s10792-02101936EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium
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