September 2006


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A First Encounter With IFIS

Editor's note: In the months following my initial report with John Campbell, MD, of intraoperative floppy iris syndrome associated with Flomax (Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT), I received numerous e-mails from around the country. This e-mail, which was written by a cataract surgeon to two friends, illustrates the frustration of unanticipated intraoperative floppy iris syndrome particularly well. As a matter of interest, it was forwarded to me last year and is reprinted here with the author's permission.
–David F. Chang, MD

March 22, 2005

Boys, I just had my first (known) experience with Flomax. Since learning about it I started screening for it in all my cataract consults but I did not go back and review those patients already scheduled for surgery. I had an 80 yo man with a pupil of about 5mm. I usually don't stretch at this size–try to get it to 6mm with Healon GV or 5. He had a very dense nuclear cataract. Everything went fine until started the irrigation from the phaco. His pupil constricted to 2mm and prolapsed through the incision at the same time. Now my virtuoso performance really begins. I stretch the pupil. Can't keep the iris in the eye or out of the phaco tip. Move the incision superiorly and more scleral–iris still prolapses. Use Healon 5 to keep iris down while I phaco. Break capsule. Lose half of the nucleus. Suddenly, I recall Tom telling me about Flomax. Ask anesthesia if he is on Flomax. Patient hears and says, "Yes, since it first became available." [Expletive deleted] Put iris hooks in. Float fragment up via viscoelastic through the pars plana. Sheets glide under the fragment and phaco. Vitreous and Healon 5 all over everything from anterior vitreous forward. Amazingly anterior capsulorrhexis intact so put IOL in sulcus with iris fixation prolene. Pupil did constrict with Miostat, which was only part of case that went well. Third case of the day with 12 more to go before noon. Over an hour behind schedule. Patient called 5 pm in pain. IOP 65 from [expletive deleted] Healon 5. Tapped the paracentesis. Diamox, brimonidine, timolol. Patient called 9pm with pain. IOP 60's. Tapped the paracentesis. Patient called 2am in pain. Have been meeting him at the suburban clinic where I work. Meet him there again. My security card will not unlock the door. Call Kaiser security–I am not authorized to be in the building past 10pm. Looking through the window I see 5 janitors cleaning the place ... but the doctor is not allowed in. Instructed to go with old patient to backside of the building to security camera so Security can get a good look at us. Finally get in, tap the paracentesis again. Next morning, IOP still up. Can see Healon 5. Cancel clinic. Back to OR. Wash out viscoelastic. Preop acuity = 20/80. Post-op acuity = HM. Corneal edema 10+. Boys, if you don't believe Chang, believe me–Flomax is bad. I will definitely use iris hooks at the beginning of the case on anybody taking this stuff along with a long tunnel. Don't be lulled into thinking you can work with the iris as I did. You can't … the sphincter constricts with no counteraction from the dilators as soon as there is any turbulence in the eye. Stretching the pupil is the worst thing you can do.

Note: Healon GV and Healon 5 (Advanced Medical Optics, Inc., Santa Ana, CA); Prolene (Ethicon Inc., Somerville, NJ); Miostat (Alcon Laboratories, Inc., Fort Worth, TX); Diamox (Duramed Pharmaceuticals, Inc., Cincinnati, OH).