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Safety of 1.8 mm Microincision Cataract Surgery in Intraoperative Floppy-Iris Syndrome Cases

Mitchell A Jackson MD Lake Villa IL USA mjlaserdoc@msn.com. Safety of 1.8 mm Microincision Cataract Surgery in Intraoperative Floppy-Iris Syndrome Cases. Relevant financial disclosure: Member Bausch + Lomb speaker’s bureau. Intraoperative Floppy Iris Syndrome (IFIS).

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Safety of 1.8 mm Microincision Cataract Surgery in Intraoperative Floppy-Iris Syndrome Cases

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  1. Mitchell A Jackson MD Lake Villa IL USA mjlaserdoc@msn.com Safety of 1.8 mm Microincision Cataract Surgery in Intraoperative Floppy-Iris Syndrome Cases Relevant financial disclosure: Member Bausch + Lomb speaker’s bureau

  2. Intraoperative Floppy Iris Syndrome (IFIS) • First described by Chang and Campbell in 20051 • Excessive billowing/floppiness of mid-peripheral iris may lead to: • Iris prolapse at main and/or side incisions • Progressive miosis • Poor preoperative pupil dilation • Complication rate overall is 77%2 • Posterior capsule rupture/vitreous loss (23%) • Iris trauma (52%) • 49% of ophthalmologists would have their own cataract removed first-even at early stage-prior to starting tamulosin (1) Chang D, Campbell J. JCRS 2005;31:664-67.(2) Chang D et al. J Cataract Refract Surg 2008;34:1201-1209.

  3. IFIS • Well established with systemic use of alpha-1 adrenergic antagonists • Tamsulosin (Flomax), Silodosin (Rapaflo) – BPH tx • Can even occur with nonspecific alpha-1 antagonists • Terazosin (Hytrin), Doxazosin (Cardura), Alfuzosin (Uroxatral) • Alpha-1a receptor subtype predominates in prostate and iris dilator muscle • Stopping treatment preop is unpredictable and IFIS has been reported for up to several years after stopping tamulosin

  4. Current Treatment Options • Masket1 • Preoperative atropine 1% drops tid for 1-2 days • Intraoperative 1:2500 epinephrine hydrochloride • Potential acute urinary retention so don’t stop tamulosin • Packard2 and Shugar3 • Intracameralphenylephrine/epinephrine preservative-free solutions in appropriate diluted mixture • Bimanual microincisional cataract surgery with its smaller, tighter incisions plus keeping irrigation inflow anterior to the iris may also lessen IFIS4 (1) Masket S, Belani S. JCRS 2007;33:580-582. (2) Gurbaxani A, Packard R. Eye 2007;21:331-332. (3) Shugar J. JCRS 2006;32:1074-1075. (4) Chang D, Campbell J. JCRS 2005;31:664-67.

  5. Current Treatment Options • OVD “donut” in anterior chamber1 • Cohesive OVD (Healon 5) peripherally and dispersive OVD (Viscoat) centrally • Dispersive OVD resists aspiration, delaying evacuation of cohesive OVD over the iris • Mechanical expansion devices • Most are bulky and difficult to position in small pupils (<4 mm) or shallow anterior chambers • Newer Malyugin rings limited to 2.2 mm incision size • Iris Retractors/Hooks • Subincisional (main and side) hooks (4) retract iris downward and out of path of phaco tip and 2nd instrument (Diamond configuration)2 • Subincisional hook (1) at main incision with adequately dilated pupil3 (1) Chang D et al. Ophthalmology. 2007;114:957-64. (2) Oetting T, Omphrov L. JCRS 2002;28:596-598. (3) Tint et al JCRS 2009;35:1849-1852.

  6. My Technique • Simple and efficient • Combine microincision cataract surgery (MICS) through 1.8 mm incision with: • Single iris hook if pupil dilation is good • Diamond 4-hook technique if pupil dilation is poor • Stellaris fluidics provides high level of chamber stability • Tight seal of MICS seems to minimize iris prolapse toward phaco incision

  7. Evaluation • Retrospective review of 20 eyes of patients who were prescribed tamulosin • Good pupil dilation • Planned uncomplicated 1.8 mm coaxial MICS with Stellaris system • Topical and intracameral anesthesia only

  8. See Video

  9. Data Summary • No complications • No posterior capsular/zonular compromise or vitreous loss • No iris trauma or pigmentation changes • Phaco times approached those of non-tamulosin cases reported in Stellaris system evaluation

  10. Stellaris Evaluation1488 cases from 46 MD’s in 13 countries Data from Bausch + Lomb

  11. Conclusions • Stellaris 1.8 mm coaxial MICS and single subincisional iris retractor maintains stable anterior chamber with minimal to no iris prolapse • With poorly dilated pupil, use 4 hooks in diamond configuration • Phaco efficiency and times essentially unchanged with tamulosin cases acting like and approaching safety rates of non-tamulosin cases

  12. Tamulosinin Cataract Surgery not so bad after all!

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