Intraoperative floppy iris syndrome continues to challenge cataract surgeons, survey finds

Results of a recent survey by the American Society of Cataract and Refractive Surgery Cataract Clinical Committee provide insight into the clinical issues facing cataract surgeons and their patients taking alpha blocker drugs. Intraoperative floppy iris syndrome continues to challenge cataract surgeons and especially seems to be associated with tamsulosin (Flomax, Boehringer Ingelheim Pharmaceuticals), according to respondents.

Key Points

Cataract surgeon: "Your cataracts are much worse and are ready for surgery. Your pupils don't dilate very well, though. Have you ever taken tamsulosin?"

Patient: "Oh yes. I forgot to mention that, doctor."

Cataract surgeon: "When did you start taking it?"

Cataract surgeons know that alpha blockers such as the systemic alpha-1 adrenergic antagonist tamsulosin (Flomax, Boehringer Ingelheim Pharmaceuticals) can cause intraoperative floppy iris syndrome (IFIS). Therefore, they routinely question patients preoperatively about their use of such drugs. Results of a recent survey conducted by the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee, however, suggest that even when an ophthalmologist is able to anticipate IFIS, cataract surgery remains difficult and is associated with higher risks of complications in patients with a history of alpha blocker use.

"Many clinical questions about IFIS continue to be debated," David F. Chang, MD, chairman of the ASCRS Cataract Clinical Committee, told Ophthalmology Times. "Is the severity or frequency of IFIS the same or less with other alpha blockers compared with tamsulosin? What is the best surgical strategy to manage IFIS? Is the complication rate still higher with IFIS when it is anticipated and recognized? Should all patients be seen by an ophthalmologist prior to starting systemic alpha blocker therapy? Because of these questions, our committee decided to conduct a survey of ASCRS members to learn more about their opinions and clinical experience with IFIS."

A link to the online survey, which consisted of 26 multiple-choice questions, was e-mailed to 6,000 ASCRS members in March; 957 members responded, 75% of whom said they were from the United States. Results were published in the July issue of the Journal of Cataract and Refractive Surgery (2008;34:1201-1209).

Dr. Chang, who with John R. Campbell, MD, first described IFIS and its association with tamsulosin in 2005 (J Cataract Refract Surg. 2005;31:664-673), said he believes that the survey is the largest one conducted to date about clinical experience with IFIS. "Unlike with some earlier surveys, these respondents presumably were able to recognize and anticipate IFIS by knowing the patient's medication history," he said. Dr. Chang also is a clinical professor of ophthalmology at the University of California, San Francisco.

Major findings

Among the major findings of the survey, he said, 95% of respondents reported that tamsulosin use by patients makes cataract surgery more difficult, and 77% expressed a belief that surgical risk is increased in patients with a known history of taking the drug.

"It was interesting to see that even if IFIS can be anticipated, three out of four doctors feel that it still increases the risks of cataract surgery," Dr. Chang said.

Approximately 52% of respondents said they had seen significant iris damage at a rate that was higher in patients with IFIS than in patients without IFIS during the 2 years preceding the survey, and 24% said that the rate of posterior capsule rupture they saw in patients with IFIS was higher than the rate in non-IFIS patients during the 2 years preceding the survey.

"The Cataract Clinical Committee felt that these were very significant findings," he said. "This indicates that IFIS is a continuing challenge for many surgeons, and just telling an ophthalmologist that you are taking an alpha blocker doesn't necessarily eliminate the risks."