SAFETY OF 1.8 MM MICROINCISION CATARACT

SURGERY IN INTRAOPERATIVE FLOPPY-IRIS SYNDROME CASES

Mitchell A Jackson MDLake Villa IL USA

mjlaserdoc@msn.com

Relevant financial disclosure: Member Bausch + Lomb speaker’s bureau

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.

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

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

Intracameral phenylephrine/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.

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.

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

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

See Video

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

Stellaris Evaluation1488 cases from 46 MD’s in 13 countries

Mean Effective Phaco Time (EPT) Power

1.8mm Coaxial-MICS 4.6 sec 12.5%

1.8mm Biaxial-MICS 2.8 sec 10.8%

2.8mm Standard Cataract Surgery 5.1 sec 13.0%

Data from Bausch + Lomb

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

Tamulosin in Cataract Surgery not so bad after all!