a.a. chen, md, ms

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incidence of floppy-iris syndrome during cataract
extraction by resident physicians

• a.a. chen, md, ms
• m.c. wu, md
• j.p. kelly, phd
• a. bhandari, md
• university of washington
• department of ophthalmology
• seattle, wa
• the authors have no financial interest in this
  project

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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)

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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
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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

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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

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METHODS

• 81 of 1163 cataract extractions were performed by
  resident physicians on patients taking tamsulosin
• operative notes for these cases were reviewed
• the 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

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RESULTS

• mean age of subjects was 76.5 years, SD 7.6
• 26 of 81 eyes (32.1) received prophylactic ILE
• with 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 (P0.174 by fishers exact
  test)

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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 lt 6.5 mm in diameter
• given the above definition, 29 of 75 (38.7) of
  preoperative dilated pupils were reported as
  small

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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 (P0.014 by
  fishers exact test)

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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 lt 6.5 mm
  were significantly associated with intraoperative
  pupil constriction

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CONCLUSION

• this retrospective studys 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

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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.
  13361339.
• 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. 4042.
• 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 a1-adrenoceptor
  antagonist, Am J Ophthalmol 143 (2007), pp.
  150151.
• 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. 957964.
• M.-C. Blouin, J. Blouin, S. Perreault, A.
  Lapointe and A. Dragomir, Intraoperative
  floppy-iris syndrome associated with
  a1-adrenoreceptors comparison of tamsulosin and
  alfuzosin, J Cataract Refract Surg 33 (2007), pp.
  12271234.
• 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.