Surgeons take steps to manage growing prevalence of IFIS
Denise M. Visco, MD, and Audrey R. Talley Rostov, MD, share their preferred approaches to this condition.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Intraoperative floppy iris syndrome (IFIS) during cataract surgery was recognized a number of years ago but seems to be increasing in prevalence. This syndrome may add a significant challenge for the cataract surgeon. There are now several approaches to manage this condition.
This month, Denise M. Visco, MD, and Audrey R. Talley Rostov, MD, discuss their preferred methods to deal with this troublesome problem. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Omidria is preferred treatment
Intraoperative floppy iris syndrome is something we have seen more frequently in cataract surgery during the last 10 years than years prior. Certain comorbidities are associated with IFIS, but medications in the alpha blocker class that patients take for other medical conditions can also induce IFIS.
When we have a floppy iris, the pupil does not dilate as well. There is a lack of iris tone, which causes lots of iris movement, making the iris tissue vulnerable to easy aspiration by the phaco needle during cataract surgery. When that happens, the iris becomes damaged, and the situation becomes worse, further degrading the iris tone and inducing miosis. If the iris damage is significant, there can be visually significant atrophy and defects postoperatively. Furthermore, when miosis occurs during cataract surgery, a whole host of complications are more likely to happen.
Prevention with Omidria (phenylephrine 1% and ketorolac 0.3%, Omeros) is my preferred treatment for IFIS. Before Omidria, I used to use intracameral epinephrine in addition to epinephrine in the bottle. We would also use stronger dilation drops before surgery, although we still do that now as part of our protocol for patients with small pupils and those who are at risk for IFIS.
Before Omidria we used pupillary expansion devices such as iris hooks and Malyugin rings (MicroSurgical Technology) more frequently. Although effective, these devices are traumatic to the iris. If you are already dealing with an iris that is floppy and has poor tone, this literally adds insult to injury.
Omidria does two things: It not only maintains the dilation of the pupil but also improves the iris tone over the course of the phacoemulsification procedure with continued exposure to the compound. With this, you will notice that the iris becomes more rigid from the beginning of the surgery to the end of the surgery. Not only does the pupil stay open but it lowers the potential need for a pupillary expansion device, so the patient winds up with a less traumatic procedure and potentially better result.
We have better treatment for IFIS now than we did in the past. Simply using something such as epinephrine might maintain pupil dilation better, but it does not improve the integrity of the iris during cataract surgery. My choice is to use a product such as intracameral Omidria, which has plenty of post-market studies and evidence-based medicine supporting better outcomes than epinephrine alone.
- For more information:
- Denise M. Visco, MD, can be reached at Eyes of York Cataract & Laser Center, 1880 Kenneth Road, Suite 1, York, PA 17408; email: dvisco@eyesofyork.com.
Disclosure: Visco reports she is a consultant for and does research for Omeros.
Editor’s note: The financial disclosure for Denise M. Visco, MD, has been corrected to include her association with Omeros.
Use some form of epinephrine
Most eye care professionals are familiar with intraoperative floppy iris syndrome that occurs with Flomax (tamsulosin, Boehringer Ingelheim) or some of the other medications for prostate complications. There are also a number of alpha blockers used to treat hypertension. If we know that patients are on these medications ahead of time, it is useful for us in planning before surgery.
These medications are often the best predictor for potential IFIS. However, it is also important to be wary of patients who have had prior surgeries such as iridotomy or angle closure procedures, as well as patients with a history of herpes zoster.
One of the long-standing treatments that people use during cataract surgery is intraocular epinephrine. That has been my choice for many years. What I tend to do for the majority of patients is to inject a small amount of intraocular lidocaine and epinephrine.
If I know that a patient has been taking Flomax or a drug known to cause IFIS, I will inject even a little extra epinephrine at the beginning of the case. I find that generally performs well. I will also use a topical NSAID drop before surgery, usually Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb) or BromSite (bromfenac ophthalmic solution 0.075%, Sun Pharma). I try to avoid generic NSAIDs, as they can be toxic to the cornea.
There is, of course, the option to use Omidria (phenylephrine 1% and ketorolac 0.3%, Omeros), which is the branded intraocular combination of phenylephrine and ketorolac. In our surgery center, we had experienced challenges with not all doctors wanting to use it. While I think it is a useful choice in medication, there had been changes with reimbursement in the past, and more importantly, I have experienced the same results with simply using intraocular epinephrine alone.
The question comes down to, should you use Omidria or not? I think that either way, as long as you are using some form of epinephrine, you will have a better outcome.
- For more information:
- Audrey R. Talley Rostov, MD, can be reached at Northwest Eye Surgeons, 10330 Meridian Ave. N., Suite 370, Seattle, WA 98133; email: atalleyrostov@nweyes.com.
Disclosure: Talley Rostov reports she consults for, lectures for or receives support from Alcon Laboratories, Allergan, Avedro, Bausch + Lomb, CorneaGen, Shire, SightLife and Sun.
Editor’s note: This article has been updated to correct the branded components of Omidria to include phenylephrine and ketorolac. Healio/OSN regrets the error.
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