Intraoperative floppy iris syndrome (IFIS) can be approached in a number of ways depending on the surgical scenario, according to David Chang, MD, University of California, San Francisco.

"There is great variability in how the iris responds among patients with IFIS," Dr. Chang said. "We have to control it, or it may or may not work, which is why multiple strategies are needed."

The first approach that he uses, an ophthalmic viscosurgical device (OVD), provides good pupillary dilation in patients who are taking tamsulosin (Flomax, Boehringer Ingelheim Pharmaceuticals), as Dr. Chang demonstrated in a mild case of IFIS. Gentle hydrodissection, horizontal chopping, and low flow are advised in these cases, he said. The key to using an OVD is to prolong its duration in the eye. He achieves visco mydriasis by refilling the eye with a proprietary OVD, 2.3% sodium hyaluronate (Healon5, Advanced Medical Optics), as needed. However, he noted, there is a learning curve associated with the use of this OVD.

Another strategy in patients with IFIS in whom an OVD alone may not work is the use of intracameral epinephrine, which provides pupillary rigidity and eliminates any billowing of the iris. In these cases, epinephrine is mixed with balanced salt solution in a 1:4 ratio. Dr. Chang demonstrated a case in which epinephrine was used, there was no prolapse, and the iris billowing stopped. In cases of severe IFIS, epinephrine may need more time to work.

When epinephrine is ineffective, Dr. Chang reported that he combines 2.3% sodium hyaluronate and epinephrine to dilate the pupil successfully.

In patients with a small pupil, iris retractors (available from Katena and FCI) may be used when intracameral epinephrine is ineffective. Dr. Chang makes a separate stab incision from the phaco incision. The retractor forms the iris in a diamond configuration, which eliminates tenting of the iris and provides good exposure nasally for chopping.

The latest strategy is the disposable expansion ring. This device provides a 6-mm pupil diameter. The ring has a low profile allowing for easy access of the instrument to the eye. Dr. Chang said that, in his opinion, he considers one proprietary ring (Malyugin Ring, Microsurgical Technologies) to be among the easiest devices to use.