20 EyeWorld Asia-Pacific | June 2025 CATARACT by Ellen Stodola, Editorial Co-Director The Iris Prolapsed —Don’t Panic Regardless of surgical experience level, Richard Tipperman, MD, said iris prolapse is something that can occur to any surgeon occasionally. As such, knowledge of the risk factors that predispose a patient to iris prolapse, how to handle the event should it occur, and postop considerations are worth revisiting periodically. “There are a lot of different ways to manage it and mitigate it, but it is something that everyone will see on occasion, and one certainly needs to know how to manage,” Dr. Tipperman said. Predisposition And Prevention Both Dr. Tipperman and Beeran Meghpara, MD, cited intraoperative floppy iris syndrome (IFIS) as the most common risk factor for iris prolapse during cataract surgery. There are a number of medications that can cause IFIS, they both said, and other contributing factors include ocular anatomy and wound construction. Medications include most notably tamsulosin/alpha blockers, though Dr. Meghpara said other medications can contribute to IFIS. “The list keeps growing and growing,” Dr. Meghpara said of medications that can cause IFIS. “There are certain antipsychotic medications that do it, certain blood pressure medications that have been reported, certain blood thinners. When you’re in a busy cataract practice, it’s often hard to keep track of what the different medications are that a patient is taking that fall on this ever-expanding list.” Dr. Tipperman said that even if a patient is not currently on tamsulosin but had taken it in the past, it could still affect their iris. “Some patients could have been on tamsulosin 15 years ago for a month then stopped it. They forget that they were on it, but their iris will still act like they’ve been on it the entire time,” Dr. Tipperman said. “Some patients come in for cataract surgery and they’ve been on tamsulosin for some time, and they say, ‘Should I stop it for my surgery?’ but there is no benefit in stopping it. Some irises on tamsulosin behave completely normally, while others are very abnormal and prone to prolapse.” Dr. Tipperman said too shallow or too posterior of a phaco entry could entice iris prolapse, as could eyes with a smaller axial length or anterior chamber depth, according to Dr. Meghpara. “Even something as simple as a thin blue iris … if I see a thin or pale blue iris, that makes me worry a little bit,” he said. Dr. Meghpara said poor dilation can be an indicator for IFIS. “If they don’t dilate well, that is also something that will get your radar up,” he said. If you have a known IFIS case that could be at risk for iris prolapse, Dr. Meghpara said it’s important to dilate the patient as much as you can ahead of time. He said if he’s worried about proper dilation, he’ll increase the phenylephrine dose to as high as 10%. He also said the patient could be started on an atropine drop 1–3 days preoperatively to improve dilation. “There have been reports of using a topical NSAID 1–3 days before surgery that also suggest improved dilation. Just [try to] get as much dilation as you can ahead of time,” he advised. Maintaining that dilation intraoperatively can be achieved with intracameral injections of epinephrine or phenylephrine/ketorolac (Omidria, Rayner) in the irrigating solution. The latter, he said, is helpful if you have access to it from an insurance standpoint. Dr. Meghpara said it’s important with some of these cases to place incisions a little more anterior and make them a bit longer to position them farther from the limbus, reducing the risk of iris prolapse. Intraoperatively, Dr. Tipperman said overfilling with viscoelastic, overly aggressive hydrodissection, or even a speculum that’s putting too much pressure on the globe can lead to iris prolapse.
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