Intraoperative Management of Iris Prolapse

From EyeWiki

Intraoperative Floppy Iris Syndrome (IFIS) was first reported by Chang and Campbell in 2005 and is now an entity well-known among cataract surgeons. IFIS was first reported to be associated with tamsulosin (Flomax) use for benign prostatic hypertrophy, but is also associated with several other systemic medications. This syndrome is characterized by poor dilation of the pupil, intraoperative progressive miosis, iris billowing and iris prolapse at the incision sites.

Disease Entity

Intraoperative floppy iris syndrome (IFIS) is a well identified condition which was described by Chang and Campbell in 2005[1]This condition is most frequently encountered during cataract surgery (phacoemulsification) in patients who have a history of alpha1-anatgonist agents such as Tamsulosin (Flomax) and similar agents either actively or in the past. This condition may be associated with an increased rate of surgical complications (i.e. vitreous loss, posterior capsular rupture, dropped nuclear fragments or iris tissue loss/trauma). Pre-operative anticipation of IFIS by an experienced surgeon can dramatically decrease complication rates.


IFIS is characterized by the following:

  • Poor dilation of the pupil, both pre-operatively and intraoperatively
  • Iris billowing and floppiness
  • Iris prolapse through the incision sites
  • Progressive constriction of the pupil (miosis) during surgery


Systemic medication, such as use of Alpha1-anatagonist agents, may cause a decrease or lack of iris dilator smooth muscle tone. The most common agent is Flomax, a highly selective alpha1A-receptor antagonist, but other alpha-adrenergic antagonists have been reported to be associated with IFIS([2][3][4],[5]).

Risk Factors

Prior history of use of Flomax or other alpha1-anatgonist agents. Also, a poorly dilated pupil preoperatively increases the likelihood that the patient will have IFIS intraoperatively. The more fluid interacting with the posterior iris, the worse the floppy eyelid becomes intraoperatively.

General Pathology

Poor or lacking dilator iris muscle tone. The specifics of iris pathology are still being investigated.


Tamsulosin (Flomax) is a selective alpha1 blocker that works by relaxing the bladder and prostatic smooth muscle.

Alpha1 adrenergic receptor anatgonists may also cause the constriction of the iris dilator muscle. The alpha1 inhibitors bind to post-synaptic nerve endings of iris dilator smooth muscle for a prolonged period which may result in poor pupillary dilation[2][3][4]

Primary prevention

The best way to prevent IFIS is to avoid the use of Flomax or other alpha1 inhibitors in patients who have not undergone cataract surgery. The primary care physician, internist or urologist should consider the possible risks of use of alpha inhibitors, and should discuss this with the patient. A consultation with an ophthalmologist may be prudent prior to starting these medicines, as it is easy to miss the diagnosis of cataract without a fully dilated ophthalmic slit lamp examination.

For the cataract surgeon, a careful systemic review of medical history, including uninary and prostate history is critical in order to screen for patients who may have been placed on these medications. More specifically, a thorough review of medications currently or formerly used is also necessary in the preperative evaluation. Meticulous examination and analysis of pupilary dilation is also recommended during the preoperative evaluation. A prepared surgeon who anticipates IFIS will have fewer complications from the syndrome.


History use of systemic sympathtic alpha1 inhibitor for benign prostatic hyperplasia with poor dilation. Tamsulosin (Flomax) or other alpha blockers are medications widely prescribed for urinary symptoms associated with benign prostatic hyperplasia.


An older male patient with a history of benign prostatic hyperplasia who received alpha blocker (tamsulosin, terazosin and doxazosin) treatment currently or in the past. The effect of medication may occur even after one dose and may persist indefinitely. Females may also take medications that can cause IFIS, and with more medications being associated with IFIS, one must suspect it in any patient who dilates poorly in the clinic.

Physical examination

A full detail exam is very important. The patient will have a poor pupillary dilation response with no other signs.


Poor dilation with mydriatic agents


The IFIS patient is asymptomatic prior to eye surgery.

Clinical diagnosis

An older male patient with history of benign prostatic hyperplasia who used or uses alpha1 inhibitor with poor dilation. Many medications may cause IFIS and surgeons need to be aware that it can affect both males and females

Diagnostic procedures

Poor response to mydriatic/cycloplegic agents

Differential diagnosis

  • Traumatic iris atrophy
  • History of chronic pilocarpine use
  • Diabetic atrophic small pupil
  • Psuedoexfoliation syndrome


Preoperative Evaluation:

A well dilated pupil is better for surgery as poor dilation is associated with a greater risk of complications. Preparing prior to surgery is helpful. Atropine Sulfate 1% cycloplegic drops used 2-3 days prior to surgery may improve pupillary dilation.

Intraoperative Preparation:

  • The incision construction of both the main incision and the paracenteses are very important. The incisions should be slightly anterior and the main wound should be square and slightly longer.
  • Use of intracameral epinephrine was reported by the late Joel Shugar, MD. Epinephrine is a direct stimulator of iris smooth muscle it helps to reduce IFIS[6]. Dr. Masket reported the synergism between topical atropine prior to surgery and intraocular preservative free bisulfite epinephrine 1:100,00 combined with 1% preservative-free Lidocaine for IFIS[7][8]).This synergy is not universally accepted.
  • Use of ophthalmic viscosurgical devices (OVD) are also reported to help with dilation. The high-viscosity OVDs, such as (Healon5) sodium hyluronate 2.3% (Abbott Medical Optics Inc., Santa Ana, CA) and DisCoVisc (Alcon Laboratories, Inc., Fort Worth, TX), can be use to create pressure on the anterior surface of the iris and cause viscomydriasis. Injecting the OVD at the pupil margin allows for viscodilation. The OVDs may need to be instilled multiple times during the surgery to maintain dilation.
  • Manual pupil dilators with two hooks are often unhelpful.
  • Mechanical pupil dilation, either through use of multiple iris retractors (Alcon Labs Inc.) or the disposable 5-0 polypropylene Malyugin pupil expander (MicroSurgical Technology, Redmond, WA), is helpful to maintain pupil dilation.
  • Low flow parameters can be achieved on a phacoemulsification machine by decreasing bottle height, lowering vacuum rates to less than 200 mmHg, and maintaining an aspiration rate of less than 26 mL/min.

General treatment

Understanding the severity of the IFIS helps to better prepare for surgery and plan a strategy for treatment. There is a variable range of IFIS severity which is classified from mild to severe.

  1. Mild- iris billowing
  2. Moderate- iris billowing and intraoperative miosis
  3. Severe- iris billowing, miosis and iris prolapse

Treatment of IFIS is described under management.

Medical therapy

For mild to moderate IFIS ( pupil dilated size more than 5mm) medical treatment with either Atropine 1% or Epi-Shugarcaine, or both, could be beneficial to the reduction of the complexity of surgery by improving iris dilation and floppiness:

  • A preoperative dosage of topical NSAIDs one to 3 days prior to surgery may help to improve pupillary dilation and reduce iris billowing, and is commonly used by surgeons
  • Atropine Sulfate 1% one to three days prior to surgery has also been used to assist with dilation.
  • The late Joel Shugar, MD reported in 2007 on the beneficial use of intracameral preservative-free epinephrine as another pharmacological agent to directly stimulate the iris dilator muscle. The Shugarcaine is made by diluting one part 4% preservative free lidocaine and three parts BSS Plus (Alcon, Fort Worth, Tex.). The recipe for Epi-Shugarcaine in whole cc quantities is 9 cc of BSS Plus, 3 cc of 4% preservative-free lidocaine, and 4 cc of bisulphate free 1:1000 epinephrine.
  • Recently, the approval of phenylephrine 1%/ketorolac 0.3% (Omidria) has allowed for continuous irrigation of medications to allow for increased and maintained dilation during cataract surgery greatly reducing the effects of IFIS.

For moderate to severe IFIS ( pupil dilated size less than 5mm), pharmacological agents may not succeed. Then iris retractors or expanders are required. Please refer to the surgery and management section.

Medical follow up

There is no medical follow up other than postoperative care and appropriate documentation, particularly if surgery is planned on the fellow eye.


Wound Construction: Careful attention to the wound construction is important. The main surgical wound should be slightly anterior, square construction, and slightly longer.

Intracameral Epinephrine: If the pupil is well dilated with the help of Omidria or Epi-Shugarcain, then the surgery can be performed successfully with a lower flow, vacuum, and aspiration rate.

Ophthalmic Viscosurgical Devices: In addition to the pharmacologic agents mentioned previously, high viscosity retentive ophthalmic viscosurgical devices (OVDs) can be used as a "viscodilator". The retentive OVD or so-called viscomydriasis (Healon5, DisCoVisc, Viscoat) helps to dilate the pupil and to maintain a concave iris near the incisions by applying pressure to the anterior surface of the iris without preventing egress of irrigation fluid. The OVDs need to be apply to the anterior chamber multiple times during phacoemulsification by reducing the flow rate, aspiration and vacuum.

Fluidics and Surgical Techniques: A low bottle height or flow to avoid large volumes of irrigation flowing posterior of the iris diaphragm will prevent iris billowing and prolapse. A lower vacuum rate, under 200 mmHg, and lower aspiration rate, lower than 30 mL/min, helps to prevent iris prolapse. The nuclear pieces should be removed at the iris plane or anterior to the iris to direct the infusion anterior to the iris. The flip and chop lens removal technique can be used to direct the infusion anteriorly and help minimize phacoemulsification time. A bimanual microincision technique helps to reduces turbulence. In severe IFIS cases, turn off the irrigation bottle to reduce the intraocular pressure before removing the phaco tip from the eye to minimize the risk of iris prolapse

Mechanical Pupil retractors or expanders: Mechanical pupil retractors and expanders are great for moderate to severe IFIS. When the pupil dilates less than 5mm, these devices can be used safely to help with pupillary dilation. The four iris retractors, which need four paracentesis sites, can be placed in a diamond configuration by placing one of the retractors placed subincisionally. The disposable 5-0 polypropylene Malyugin pupil expansion ring (6.25 and 7mm) is a popular device for pupil dilation, without the need for additional paracenteses wounds. In addition, the device allows for a round pupil and is less traumatic to the iris sphincter and pigment.

Surgical follow up

IFIS Patients may experience a longer recovery time than a patient with an uncomplicated cataract surgery.


  • Irregular pupil
  • Iris trauma, iris tissue loss and atrophy
  • Posterior capsule tear
  • Vitreous loss
  • Dropped nucleus


Appropriate preoperative and intraoperative preparation and management will allow for the best postoperative outcomes.

IFIS Patients may experience more pain, corneal edema, a longer surgical and recovery time, and less improvement in visual acuity than a patient with an uncomplicated cataract surgery.

Additional Resources


  1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin (Flomax). J Cataract Refract Surg. 2005; 31:664-673
  2. 2.0 2.1 Schwinn DA, Afshari NA. "alpha(1)-Adrenergic receptor antagonists and the iris: new mechanistic insights into floppy iris syndrome." Surv Ophthalmol. 2006 Sep-Oct;51(5):501-12.
  3. 3.0 3.1 Parssinen O, Leppanen E, Keski-Rahkonen P, Mauriala T, Dugue B, Lehtonen M. "Influence of tamsulosin on the iris and its implications for cataract surgery." Invest Ophthalmol Vis Sci. 2006 Sep;47(9):3766-71.
  4. 4.0 4.1 Cheung CM, Awan MA, Sandramouli S. "Prevalence and clinical findings of tamsulosin-associated intraoperative floppy-iris syndrome." J Cataract Refract Surg. 2006 Aug;32(8):1336-9.
  5. Chang DF, Braga-Mele R., Mamalis N, etal; ASCRS Cataract Clinical Committee. ASCRS White Paper: Clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2008: 34(12)2153-2162
  6. Shugar JK. Prophylaxis for IFIS [letter]. J Cataract Refract Surg. 2007; 33:942-943
  7. Masket S. Belani S. Combined preoperative topical atropine sulfate 1% and intracameral preservative-free epinephrine hydrochloride 1:4000 for management of intraoperative floppy iris syndrome. J Cataract Refract Surg. 2007; 33:580-582
  8. Masket S, and Chang DF. Intraoperative Floppy Iris Syndrome A systemic approach. J Cataract Refractive Surg. Today 2010; 10(4)68-73
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