Risk factors of floppy iris syndrome: current insights

ABSTRACT

Introduction: Intraoperative Floppy Iris Syndrome (IFIS) represents one of the most challenging conditions for cataract surgeons, significantly increasing intraoperative complications rate, especially when not anticipated. We conducted a comprehensive literature review of the Medline, Scopus, and Web of Science databases. The end of the search date was 18 October 2020.

Areas covered: Patients are not equally prone to develop IFIS. Exposure to several factors predisposes to IFIS. At its first description, IFIS was correlated with tamsulosin. However, several other risk factors have been identified, including gender, age, other alpha-1 blockers, hypertension and antihypertensive drugs, benzodiazepines and antipsychotics, and a poorly dilated pupil. This study provides a comprehensive, up-to-date literature review on the factors predisposing to IFIS, the prophylactic measures that can be employed for high-risk patients, and the intraoperative management of IFIS.

Expert opinion: Although IFIS is correlated with increased complication rates, the implementation of preventive measures in high-risk patients may significantly reduce complications and surgical stress. The key to addressing IFIS is carefully assessing and documenting the predisposing factors to adequately stratify the surgical risk. Preoperative assessment of the surgical risk is vital since an unanticipated IFIS could turn an uneventful, routine surgery into one of significant visual morbidity.

KEYWORDS:

• Intraoperative floppy Iris syndrome
• IFIS
• predisposing factors
• preoperative prophylaxis
• preventive measures
• risk Factors
• intraoperative management

Article highlights

• Since its original description in 2005, Intraoperative Floppy Iris Syndrome (IFIS) has been widely established as one of the most challenging conditions for cataract surgeons.

• Numerous studies have been published in the last 15 years proving that the appearance of IFIS significantly increases the risk of intraoperative complications, especially when not anticipated.

• Several risk factors, such as alpha1-blockers intake for benign prostate hyperplasia, have been linked to the appearance of IFIS, predominantly in men, not exclusively though, as it may as well appear in female patients leading to vision-threatening complications.

• Therefore, it is critical for medical personnel being involved in the preoperative assessment of cataract patients to be able to identify high-risk cases and inform cataract surgeons accordingly.

• Patient data, including demographics, dilated pupillary size, and the intake of several medications such as alpha-1 blockers, benzodiazepines, antipsychotics, and antihypertensives, should always be reported in patients’ records.

• The use of intracameral agents, such as adrenaline, upon the beginning of surgery, as well as the employment of the newest, less traumatic pupillary expansion devices, can minimize most features of IFIS.

Authors contribition

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This manuscript was not funded.