a.a. chen, md, msm.c. wu, md

j.p. kelly, phda. bhandari, md

university of washingtondepartment of ophthalmology

seattle, wa

the authors have no financial interest in this project

incidence of floppy-iris syndrome during cataract extraction by

resident physicians

INTRODUCTION

intraoperative floppy-iris syndrome (IFIS) is a phenomenon consisting of: billowing iris iris prolapse pupil constriction

IFIS occurs among cataract surgery patients who have taken tamsulosin and/or other systemic alpha-1 antagonists

(chang et al, jcrs 2008)

INTRODUCTION

previously reported incidences of IFIS in patients taking tamsulosin:

Study Number of eyes IFIS incidence

Cheung et al, 2006 17 30.0%

Chadha et al, 2007 21 57.0%

Oshika et al, 2007 58 43.1%

Chang et al, 2007 167 90.0%

Blouin et al, 2007 22 86.4%

PURPOSE

the aims of this retrospective study were to determine: (1) the reported overall incidence of IFIS in patients taking

tamsulosin who undergo cataract extraction by a resident physician

(2) the reported incidence of IFIS in patients taking tamsulosin who receive prophylactic intracameral lidocaine/epinephrine (ILE) after paracentesis construction during cataract extraction by a resident physician

METHODS

IRB approval was obtained power and sample size calculations were performed

assuming an IFIS incidence of 86.4% among those taking tamsulosin, a power of 0.80, and an alpha of 0.05, at least 55 charts would have to be reviewed in order to detect a one-sided 15% change in incidence among those who receive prophylactic ILE

ophthalmology clinic notes and medications lists of 1163 consecutive patients who underwent cataract extraction by resident physicians at a single center between 1/2005 and 7/2008 were reviewed

METHODS

81 of 1163 cataract extractions were performed by resident physicians on patients taking tamsulosin

operative notes for these cases were reviewedthe following data were recorded for each case

preoperative dilated pupil diameter use of prophylactic ILE after paracentesis construction presence of billowing iris presence of iris prolapse presence of pupil constriction

RESULTS

mean age of subjects was 76.5 years, SD 7.626 of 81 eyes (32.1%) received prophylactic ILEwith IFIS defined as the occurrence of billowing iris, iris

prolapse, and/or pupil constriction: overall incidence of IFIS = 29.6% incidence of IFIS among patients who did not receive ILE = 25.4%

OR 0.7, 95% CI = 0.36 to 1.3 incidence of IFIS among patients who received ILE = 38.5%

OR 1.2, 95% CI = 0.85 to 1.8

use of prophylactic ILE did not decrease the incidence of IFIS (P=0.174 by fisher’s exact test)

RESULTS

preoperative dilated pupil diameter was reported in 75 of 81 operative notes

mean preoperative dilated pupil diameter was 6.6 mm SD 1.3

small preoperative dilated pupils were defined as those with < 6.5 mm in diameter

given the above definition, 29 of 75 (38.7%) of preoperative dilated pupils were reported as small

RESULTS

among patients with small preoperative dilated pupils, the incidence of intraoperative pupil constriction was 37.9%

among patients with large preoperative dilated pupils, the incidence of intraoperative pupil constriction was 13.0%

the presence of a small preoperative dilated pupil was significantly associated with intraoperative pupil constriction (P=0.014 by fisher’s exact test)

CONCLUSION

in this retrospective study of patients taking tamsulosin who have undergone cataract extraction by resident physicians: the reported incidence of IFIS was 29.6% the use of prophylactic intracameral lidocaine and epinephrine

after paracentesis construction did not reduce the reported incidence of IFIS

the above incidence is lower than previously reported values preoperative dilated pupil diameters < 6.5 mm were significantly

associated with intraoperative pupil constriction

CONCLUSION

this retrospective study’s limitations include possible confounding bias and recall bias

further investigation is needed to clarify further the epidemiology of IFIS and determine possible methods for IFIS prophylaxis

REFERENCES

C.M.G. Cheung, M.A.R. Awan and S. Sandramouli, Prevalence and clinical findings of tamsulosin-associated intraoperative floppy-iris syndrome, J Cataract Refract Surg 32 (2006), pp. 1336–1339.

V. Chadha, S. Borooah, A. Tey, C. Styles and J. Singh, Floppy-iris behaviour during cataract surgery: associations and variations, Br J Ophthalmol 91 (2007), pp. 40–42.

T. Oshika, Y. Ohashi, M. Inamura, K. Ohki, S. Okamoto, T. Koyama, I. Sakabe, K. Takahashi, Y. Fujita, T. Miyoshi and T. Yasuma, Incidence of intraoperative floppy-iris syndrome in patients on either systemic or topical α1-adrenoceptor antagonist, Am J Ophthalmol 143 (2007), pp. 150–151.

D.F. Chang, R.H. Osher, L. Wang and D.D. Koch, Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax), Ophthalmology 114 (2007), pp. 957–964.

M.-C. Blouin, J. Blouin, S. Perreault, A. Lapointe and A. Dragomir, Intraoperative floppy-iris syndrome associated with α1-adrenoreceptors; comparison of tamsulosin and alfuzosin, J Cataract Refract Surg 33 (2007), pp. 1227–1234.

D.F. Chang, R. Braga-Mele, N. Mamalis, S. Masket, K.M. Miller, L.D. Nichamin, R.B. Packard, and M. Packer. ASCRS White Paper: clinical review of intraoperative floppy-iris syndrome, J Cataract Refract Surg 34 (2008), pp. 2153-2162.