Range of severity of IFIS requires varied management strategies

KOLOA, Hawaii — Because the severity of intraoperative floppy iris syndrome can vary significantly between patients and even between two eyes of the same patient, cataract surgeons need a variety of tools to handle any scenario, according to David F. Chang, MD.

Speaking here at Hawaiian Eye 2007, Dr. Chang said symptoms of intraoperative floppy iris syndrome (IFIS) can range from mild, marked by good dilation but a slight billowing, moderate, marked by some tendency for iris prolapse and some pupillary constriction, to severe, categorized by classic triad and poor preoperative dilation.

Surgeons should determine a patient's history of alpha-blockers in order to know which strategy should be employed, either alone or in combination, said Dr. Chang, an OSN Cataract Surgery Section Member.

In mild to moderate cases, Dr. Chang said he takes an adjunctive pharmacologic approach. Intracameral alpha agonists, such as phenylephrine and epinephrine can be effective in adding "greater tone to the iris dilator smooth muscle, resulting in a more rigid iris," Dr. Chang said.

"It makes the iris very rigid and prevents the billowing you would normally see when the [viscoelastic] is removed," he said. "It's a wonderful adjunct for any small pupil case."

He cautioned that only unpreserved solutions should be used, and that mixtures should be diluted to buffer the pH level.

Dr. Chang also discussed iris retractors as a "100% reliable" strategy for pupil expansion in IFIS patients.

"For very severe cases there is nothing like iris retractors," he said.

The hook is placed subincisionally to retract the iris downward and away from the phaco tip, "giving great chopping exposure." He added he uses 4-0 polypropylene retractors from Katena, which he said are easy to manipulate. They are also cost-effective because they can be repeatedly autoclaved.