Two approaches to treating IFIS

How I use intracameral drugs and the tri-soft shell technique

By Steve A. Arshinoff, MD

About the Author
	Steve A. Arshinoff, MD, is clinical instructor of ophthalmology at the University of Toronto. Disclosures: Dr. Arshinoff disclosed relationships with Alcon Laboratories, Abbot, Anteis, Bausch + Lomb and iMed Pharma.

All cataract surgeons worry about intraoperative floppy iris syndrome because of the increased use of Flomax (tamsulosin, Boehringer Ingelheim Pharmaceuticals, Ingelheim, Germany) by our patients, but I believe my approach, using ophthalmic viscosurgical devices (OVDs) and a unique combination of intracameral drugs, both renders these cases simple and maintains efficiency. Here, I explain my approach to IFIS.

PREOPERATIVE PREVENTION

Pupil dilation test

I try to see all the patients taking Flomax a week or two before their surgery, and I do a simple dilation test (Figure 1). I have my staff administer two drops of tropicamide 1% and one drop of phenylephrine 2.5%. I sit the patients down for 15 minutes, and then I look at their pupils.

Figure 1: This simple test will help determine if pupil dilation will be a problem during surgery.

If their pupils are bigger than, say, 6.5 mm, meaning fairly normal dilation, I do not anticipate any problems. If their pupils are smaller than 5 mm, it’s a problem. In between are gradations of potential IFIS difficulty.

It’s a simple test that will indicate if the surgery will be difficult. I mark the result on their chart before surgery, so I know what to expect.

Consider other culprits

I also want to see if the problem with a smaller pupil truly is IFIS, and only IFIS, because sometimes it’s not. I’ve had patients who have been on Flomax but also had a history of iritis, some four or five times, and posterior synechiae or a somewhat atrophic iris for another reason.

A patient may have a fibrotic pupillary ring, either from previous miotic use or simply age. All you have to do is peel off the ring; it’s not the Flomax at all. I still stretch pupils that are miotic secondary to fibrosis. On the other hand, the last thing you want to do with a pupil of a patient on Flomax is to stretch a floppy iris, because that makes it more floppy.

Another telltale sign the patient does not have IFIS is a unilateral presentation; IFIS is always bilateral.

However, sometimes the patient has a fibrous iris from previous inflammation, and you want to stretch it and treat Flomax-induced IFIS as well. With the preoperative dilation test, you are just looking at the patient to observe what’s wrong, because even though she or he has been on Flomax, it does not mean the patient has no other pathology. Some people have other concomitant problems as well as IFIS.

The most important thing is to examine the patient. Like everything in ophthalmology, if you look at the patient first, the subsequent surgery becomes a lot easier. Stretching fibrous pupils and using the IFIS bridge OVD technique for Flomax patients are not mutually exclusive. I’ve often done both in the same eye.

Educate the PCP

Another thing I do with Flomax patients is give them a letter to hand to their primary care physician. Now, I know full well that the letter makes no difference at that point; I realize that particular patient will not really fare any better in cataract surgery changing from Flomax to Xatral (afluzosin, Sanofi, Paris) or another non-specific alpha blocker.

But the letter does let the family doctor or urologist know you are concerned about the patient taking this drug. Essentially, the letter says to the doctor: “I am concerned that you gave this patient this drug. Was there no other choice? He has to have cataract surgery and his risks are now increased from this drug.”

The result is that over the last few years, urologists and family doctors who refer to me are a bit more careful about putting people on Flomax long term.

AVOIDING COMPLICATIONS IN THE OR

Prepare the anterior chamber for IFIS

I have the OR nurses double dose the balanced salt solution (BSS) bottle with adrenalin. We always put in the standard 0.5 cc of adrenalin, but I give Flomax patients twice that standard amount. While this probably makes very little difference medically, it makes the nurse do something out of the norm, so now she’s aware this is a potentially difficult Flomax patient.

Now the nurse knows not to leave the OR during the operation because I may want to adjust the flow rates or make another adjustment for this patient. Otherwise, the nurse lays the patient down, the scrub nurse starts, and the circulating nurse may go to another room.

Making corneal incisions

I make the corneal incisions longer to avoid iris prolapse. When you make your incisions, you don’t want the iris to pop out through the incision, and there is a significant risk of this in a floppy iris case. Longer incisions prevent this because a floppy iris will go under the incision and not through it.

Once I make the incision, I inject a xylocainephenylephrine mixture. I give all my patients intracameral xylocaine, and I mix the xylocaine into a combination I call XYLO-PHE. In Canada — unfortunately, not in the United States, but everywhere else in the world — you can purchase minims sold by Bausch + Lomb of 10% phenylephrine.

I take the entire minim (0.3 cc) of this 10% phenylephrine and add it into a 6-cc syringe containing 5 cc BSS. I roll it in my hand to mix it, and when the nurse is about to place the intracameral xylocaine on the scrub nurse’s tray, I ask the nurse to add a few drops of this sterile phenylephrine mixture solution into that xylocaine.

This effectively gives you a 1:300 dilution. You might think that wouldn’t do anything, but it’s amazingly efficacious.

The pupils dilate to approximately 8 mm. Because xylocaine is the most effective drug to paralyze the sphincter and phenylephrine is the most potent agonist to dilate the dilator, together they give the best dilatory effect (Figure 2).

Figure 2: My XYLO-PHE combination dilates the pupil to approximately 8 mm.

Sideport incision

When I make the sideport incision, first I inject 0.1 or 0.2 cc of XYLO-PHE into the anterior chamber. It delivers anesthesia and creates excellent dilation within about 5 seconds. Then I know exactly where I stand with the patient’s degree of IFIS.

Using this xylocainephenylephrine mixture has made the rest of the protocol of dealing with Flomax patients necessary only occasionally.

THE TRI-SOFT SHELL TECHNIQUE

Creating the soft-shell ‘bridge’ variant

My tri-soft shell technique for Flomax IFIS involves creating a “soft-shell bridge.”¹

First I inject Viscoat (Alcon Laboratories, Fort Worth, Texas) (Figure 3). I do this not only to protect endothelial cells, but also to cover the entire iris. This is because if you aspirate any OVD — say, Healon5 or Healon (AMO, Abbott Park, Ill.) or any of the viscous cohesives — all the viscoelastic of that type will come out when you go back and put the I/A in the eye or the phaco. However, if the OVD is dispersive and you grab a piece accidentally, it won’t come out. It will just disperse; a little piece will come out and the rest will still cover the iris, preventing flopping.

Contrary to the common theory that you want a very viscous, cohesive device covering the iris, you actually want a dispersive covering over the iris. But you want to push that aside with a viscous cohesive.

OVD aids dilation

After I coat the perimeter of the entire iris with Viscoat, I inject Healon5 into the middle of the anterior chamber (Figure 4) and apply a bit of pressure. That pushes the iris and the Viscoat out as far as I can get it, so I get a more dilated pupil.

Then I inject more of the XYLO-PHE mixture underneath the Healon5, just on top of the capsule (Figure 5). That allows me to do the capsulorhexis in low resistance BSS, which is much easier than working in a viscous solution of Healon5 or visco-adaptive.

Figures 3, 4 and 5: To build an OVD bridge, first coat the entire iris with Viscoat (3). Then inject Healon5 into the middle of the anterior chamber (4). Finally, inject more XYLO-PHE mixture under the Healon5 and on top of the capsule (5).

Making the capsulorhexis

For the capsulorhexis, I use a bent needle rather than a forceps because that works better when working in a small, thin area of BSS, and is less likely to disrupt the IFIS bridge. I keep the capsulorhexis smaller than the pupil so the subsequent turbulence of phaco remains in the capsular bag and does not disturb the iris.

Once I complete the capsulorhexis, I hydrosect with brief spurts of fluid to not disturb the OVD layers I place. When I go into the anterior chamber, I wiggle the cannula a bit to break the Healon5 layer, which is usually blocking the entry (and BSS exit). Then, the circulating BSS around the nucleus will flow out easily without making all the OVD layers come apart.

I hydrosect the nucleus a lot, probably more than I think I have to. The looser the nucleus, the easier the rest of the operation goes. And once you get the flow going underneath the OVD layers, it’s actually very easy to do this and you do not lose the OVD IFIS Bridge.

PERFORMING PHACO

Lower flow, turbulence rates

Once I’m finished hydrosecting, I lower the flow rates. I use the vacuum as high as only about 200, and a flow rate of about 20. The bottle height should be approximately 75 cm above the patient’s head. Following these guidelines makes the whole anterior chamber remain more stable and you tend to not break the Healon5 layer that protects the other layers in the anterior chamber. I work in the fluid layer behind it.

When I’ve finished the phaco, all the layers of OVD are still intact, the lens is gone and all I have to do is the I/A. I have already hydrosected, so the cortex is reasonably free. Then I take the I/A and zip around the edge of the capsulorhexis, catching the frilly edges, which come out pretty easily. Then I put the IOL into the bag.

Advantages of OVD

I use OVDs for IFIS patients, rather than hooks or rings, because they make the surgery easier. I think the goal of any surgeon should be to be a really lazy surgeon — you want to have the phaco machine or OVDs, or both, do things for you and not have to get Morcher hooks or a Malyugin ring and keep playing around.

All ancillary devices add more steps and potentially more trauma to the eye. Instead of taking that risk, you can just put these OVD fluids in the eye and stabilize it and it makes your life easier. The case takes maybe one minute longer than a regular cataract surgery, and the cases are easy.

Further, if you address the IFIS surgery with OVDs, they are like regular cataract cases. Postoperatively you give these patients your regular eyedrops, you watch them and they’re fine. So I urge you to consider using OVDs for your Flomax cases. Once you catch on to how OVDs work, which is that they are all different and do different things, they make dealing with IFIS cases much easier. OM

REFERENCE

1. Arshinoff SA, Norman R. Tri-soft shell technique. J Cataract Refract Surg. 2013; 39:1196-1203.

How I use Malyugin rings and a supracapsular approach

By Frank A. Bucci Jr., MD

About the Author
	Frank A. Bucci Jr, MD, is medical director at Bucci Laser Vision Institute, Wilkes-Barre, Pa. His e-mail is buccivsion@aol.com. Disclosures: Dr. Bucci had not disclosed any financial relationships by press time.

I frequently see patients with intraoperative floppy iris syndrome (IFIS) in my surgical practice. It is usually because they are on Flomax, a drug that has become very popular among the cataract-age population.

It is imperative we develop a well-thought-out strategy for dealing with these patients.

PREOPERATIVE STEPS

Flomax effect persists after cessation

The first thing is to identify patients with poor dilation during the preoperative visit and determine during the history if they are using or have used Flomax. Patients may have stopped Flomax but the effect can persist afterward. Flomax is the most selected alpha blocker, and thus has the potential of creating the most severe cases of IFIS.

Poor dilation, a flaccid or floppy iris and the occurrence of iris prolapse at the wound characterize IFIS. You need to rule out other causes of poor dilation, such as diabetes or posterior synechia, because stretching the iris with IFIS makes this condition worse.

Preparing the poorly dilating pupil

Before we discuss the specific maneuvers for directly dealing with the poor dilation and floppy iris of IFIS, a review of these supporting strategies can be helpful in treating almost all cases of a poorly dilating pupil, although they are not specific to IFIS:

• NSAIDS. Their use preoperatively with all cataract surgery should almost be a given. Their inhibition of miosis and anti-inflammatory effects (after excessive manipulation of the iris) are welcome with all cataract surgeries, but are especially useful for Flomax patients.
  I administer NSAIDs four times a day for three days preoperatively and four times in the hour before surgery.
• Epinephrine. Intracameral epinephrine (1:4,000) in a buffered solution can sometimes support dilation and inhibit miosis. I use it routinely in Flomax patients.
• Trypan blue. In moderate and severe cases of IFIS with limited dilation, the red reflex can be poor. I use Trypan blue to dye the capsule. The visual clues that result can be useful when performing a capsulorhexis with a small pupil and a limited red reflex.
• Honan balloon and mannitol. I routinely use a Honan balloon for a minimum of 10-15 minutes preoperatively for all my cataract patients. If a Flomax patient demonstrates poor dilation in the clinic, I extend the Honan balloon time to at least 30 minutes immediately preoperatively.
  

If the patient has a history of hyperopia or has a crowded anterior chamber, I will administer IV mannitol 12.5 g before the Honan balloon. This assures a soft eye without positive posterior pressure when dealing with a challenging iris, as in Flomax cases.

IFIS has primarily been linked to FLomax, although recent research has uncovered other causes of the syndrome.

Why not atropine?

Some surgeons are proponents of having patients use atropine 1% for two days preoperatively. I am not a fan of this treatment. For one thing, I am not sure that it really adds a great deal to maximizing dilation. Further, a potential side effect is difficulty with urination — which is the reason the patient is taking Flomax in the first place.

Most reports do not show a significant reduction in the incidence and severity of IFIS if the medication is discontinued before surgery. For this reason and for not wanting to aggravate their urinary symptoms, I do not ask patients to discontinue Flomax preoperatively.

STEPS IN THE OR

Supracapsular technique

Techniques that I have used for manipulating and managing the pupil with IFIS include iris hooks, Healon5 (AMO, Abbott Park, Ill.), and the Malyugin ring (Halma plc, Amersham, UK).

However, adoption of a supracapsular technique for manipulation of the nucleus at the time of phaco has had the most significant impact on how I manage mild and moderate cases of IFIS.

I rotate the nucleus 90° in the iris plane. Then I use my regular viscoelastic to push the iris posterior, exposing almost two-thirds of the whole nuclear-epinuclear complex.

This complex is then consumed from outside to inside while using moderately high vacuum settings with a Venturi pump phaco.

I take care to lower the vacuum levels to less than the usual maximum vacuum setting on a normal case because the floppy iris can easily come to the phaco tip if the surgeon is not careful. This supracapsular technique has significantly reduced my use of iris hooks and Healon5 over the past four years.

Simultaneously, I have increasingly found the Malyugin ring to be an efficient and effective tool for dealing with moderately severe and severe IFIS.

Keeping it simple

So I perform almost all cases of potential IFIS with the backdrop of NSAIDs, Trypan blue, extra Honan balloon with mannitol, and intracameral epinephrine.

Thereafter, the decision tree becomes very simple: Do I need a Malyugin ring or do I proceed with cautious efficiency with my supracapsular technique? Now I use Healon5 only occasionally, and rarely resort to iris hooks.

Experience has made it relatively clear when I need to add the Malyugin ring to my surgical plan. I prefer the 6.25-mm ring (Figures 1, 2 and 3). The Malyugin ring is relatively easy to place and remove. Additionally, it provides a consistent 5–6-mm pupil through which to work. OM

Figures 1, 2 and 3: The Malyugin ring is easy to place (1) as well as remove (3), and it provides a consistent 5–6-mm pupil for IFIS cases in which the surgeon can work (2).