About MEAJO | Editorial board | Search | Ahead of print | Current Issue | Archives | Instructions to authors | Online submission | Subscribe | Advertise | Contact | Login 
Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
Users Online: 1663   Home Print this page Email this page Small font sizeDefault font sizeIncrease font size


 
  Table of Contents 
REVIEW ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 1  |  Page : 51-56  

Intraoperative floppy iris syndrome induced by tamsulosin: The risk and preventive strategies


1 Department of Pharmacology, College of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
2 Department of Ophthalmology, College of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
3 Department of Pharmacy Practice, Pharmacy Practice Research Unit, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
4 Department of Pharmacology and Toxicology, College of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt

Date of Submission31-Dec-2020
Date of Acceptance17-Mar-2021
Date of Web Publication30-Apr-2021

Correspondence Address:
Dr. Mansour Tobaiqy
Department of Pharmacology, College of Medicine, University of Jeddah, PO Box 45311, Jeddah 21512
Kingdom of Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_561_20

Rights and Permissions
   Abstract 


Tamsulosin is an antagonist of a subtype-specific alpha-1A- and alpha-1D-adrenoceptor (AR) that is expressed in the prostate gland, urethra, and bladder. Several reports have shown a possible relationship between ophthalmologic adverse effects and the use of alpha-1-receptor medicines, including tamsulosin. This descriptive review evaluates the intraoperative floppy iris syndrome (IFIS) associated with tamsulosin. A search of the Medline and PubMed databases was conducted to identify control trials, case reports, and observational examinations published in English. The publication dates were restricted (January 1, 2000, to January 1, 2020). Keywords (tamsulosin, alpha-blocker, ocular, eye, adverse reaction, and IFIS) were used in the searches. The searches identified 66 studies including in vitro or in vivo studies, trials, and observational studies. Twenty-two (33.33%) studies were articles citing tamsulosin and IFIS as having confirmed potential risk to ocular safety. The results of this review, including a comprehensive summary of published research on tamsulosin use in different populations, have identified several articles showing associations between tamsulosin and IFIS that merit further investigation. Suspending of potential causative pharmacological treatment of IFIS before ocular surgery including tamsulosin, proper identification of at-risk patients, preoperative prophylaxis treatments, and surgical technique modifications clearly can mitigate the anticipated risk of IFIS induced by tamsulosin.

Keywords: Alpha-1-adrenergic receptor antagonist, intraoperative floppy iris syndrome, ocular, safety, tamsulosin benign prostatic hyperplasia


How to cite this article:
Tobaiqy M, Aalam W, Banji D, Al Haleem EN. Intraoperative floppy iris syndrome induced by tamsulosin: The risk and preventive strategies. Middle East Afr J Ophthalmol 2021;28:51-6

How to cite this URL:
Tobaiqy M, Aalam W, Banji D, Al Haleem EN. Intraoperative floppy iris syndrome induced by tamsulosin: The risk and preventive strategies. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2021 Sep 25];28:51-6. Available from: http://www.meajo.org/text.asp?2021/28/1/51/315323




   Introduction Top


Tamsulosin is an antagonist of a subtype-specific alpha-1A- and alpha-1D-adrenoceptor (AR) that is expressed in the prostate gland, urethra, and bladder. It can elicit a relaxation of the prostate gland and bladder smooth muscles, thereby ensuring a maximal urine flow (Qmax), while moderating the lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH).[1] Men with enlarged prostate glands experience reduced urinary streams because of bladder outlet obstruction.[1] This promotes bladder dysfunction and lower urinary tract side effects, disabled bladder draining, and urinary tract contamination. Whenever BPH is disregarded, it can lead to intense urinary retention, urosepsis, constant renal deficiency, and death auxiliary to BPH. BPH has a histological predominance of 8%, 50%, and 80% in the fourth, sixth, and ninth decades of life, respectively.[2]

Three distinctive alpha-1-AR subtypes – the alpha-1A-, alpha-1B-, and alpha-1D-ARs[3] – are dispersed generally in the prostate muscle, lower urinary tract, heart, liver, vascular tissue, and ocular muscles.[3]

The entire class of alpha-AR antagonists (ARA - 1A) can also induce intraoperative floppy iris syndrome (IFIS),[1] an adverse effect that was first reported by Chang and Campbell 15 years ago in 2005.[4] Several other therapeutics and pharmacological groups can adversely affect eye function and lead to the development of ocular adverse effects, summarized in Li et al. 2008 review, these effects including angle-closure glaucoma with certain β2-adrenergic agonists, intraocular pressure and subcapsular cataract with glucocorticoids, open-angle glaucoma in vulnerable patients with the use of the anticancer agent docetaxel, and bull's-eye maculopathy induced by aminoglycosides.[5]

Alfuzosin, terazosin, and doxazosin are also ARA α1A, but they lack the specificity of tamsulosin to α1A.[1] Each of the four medications is similarly effective in treating LUTS, but alfuzosin and tamsulosin are less likely to lead to hypotension than are the less particular alpha-blockers terazosin and doxazosin.[1],[6],[7] The prostate enlargement rate expands by 2.0%–2.5% every year in adult men,[7],[8] and this enlargement can lead to clinical BPH development, urine retention, and a requirement for prostate medical procedures, including the use of AR antagonists therapeutics to improve patient's clinical condition and quality of life.[9],[10],[11]

There are reports in the literature that demonstrates a likely relationship between alpha-AR antagonists, including tamsulosin and ocular adverse effects “IFIS.”[5],[6] Therefore, the aim of this literature review was to evaluate the incidence of IFIS associated with tamsulosin. Furthermore, the study will discuss the potential preoperative and intraoperative strategies for the management of IFIS.


   Methods Top


The search strategy looked for randomized control trials (RCTs), case reports, observational studies, and other peer-reviewed full articles published in the English language between January 1, 2000, and August 1, 2020. Research articles on quantitative observational investigations, case reports, and RCTs were mainly focused on tamsulosin, alpha-blocker, ocular, eye, adverse drug reactions (ADRs), antagonistic medication incidents, poisonous effects, IFIS, one-sided choroidal detachment, chemosis, and acute-onset myopia. The primary outcome was the prevalence of any unfavorable visual adverse effects in patients treated with tamsulosin. The secondary outcomes were dose-associated toxicity and comorbidities with tamsulosin. Up-to-date information is presented on tamsulosin and its impedance of various eye illnesses, such as IFIS. In addition, the relationship is explored between the iris smooth muscle or the prostate and the effect of possible structural changes due to persistent dosing with α-blockers. Basic clinical rules can be introduced to assist physicians in recognizing patients who would benefit from early reference for an ophthalmological assessment before initiating alpha-1-antagonist treatment.


   Results Top


The search identified 66 articles, including in vivo or in vitro studies, clinical trials, and observational descriptive studies. Of these, one-third referred specifically to tamsulosin and IFIS (n = 22, 33.33%).

In vitro studies

Animal studies have established that alpha-1A-ARs are also the most widely distributed ocular subtype and are found in the iris dilator muscle in rats[12] and rabbits.[13] The antagonism of alpha-1A-ARs by tamsulosin in the iris dilator muscle resulted in poor muscle tone and flaccid iris stroma, thus leading to fluttering and sluggish of the iris.[13],[14] In vitro studies on rabbits have demonstrated that tamsulosin can bind to iris melanin to inhibit the dilator muscle and promote IFIS.[15],[16]

Alpha-1-receptors have been recognized in the lower urinary tract and the heart, liver, and vascular and visual smooth muscle.[1],[2] The alpha-1A-AR is known to intervene in pupil expansion in rodents and rabbits; however, no human examinations have been carried out.[11] The iris dilator smooth muscle blockade causes iris tone deterioration by the parasympathetically innervated iris effect that promotes clinical IFIS.[16]

The studies have shown that tamsulosin has a greater affinity for the alpha-1A-AR than for the alpha-1B-AR and the alpha-1D-AR. Tamsulosin is highly bound to plasma proteins (94% to 99%), primarily alpha1 acid glycoprotein (AGP), the pharmacological activity of a drug directly relates to the unbound concentration. The unbound (therapeutic) concentration of tamsulosin following multiple dosing in men with BPH, were much greater in prostate than in blood plasma, suggesting a continued binding of tamsulosin with the target tissues. Based on this, in the iris, tamsulosin is proposed to bind for long period to the postsynaptic 1AAR of the iris-enlarging muscle.[17],[18]

Tamsulosin has also been shown to have a ten times greater potency in blocking phenylephrine-induced prostatic compression in dogs[19] and a hundred-fold greater potency in relaxation of smooth muscles in rabbits when compared with the nonselective adrenergic antagonists.[20]

The iris and alpha-1-adrenergic receptor antagonists

The iris is an intact tissue with many different layers, and its innervation directs the iris muscle tone.[21] The role of the iris smooth muscle includes an organization of competing pathways including sympathetic and parasympathetic, peptidergic, serotonergic, dopaminergic, and prostaglandin-related pathways[17] and controlling pupil size both dilation and constrictions. Dilated pupil diameter preoperatively has been considered an independent risk factor for the development of IFIS; a dilated pupil of 7.0 mm or smaller had 95% specificity for predicting IFIS in patients who have been treated with alpha-1A-AR antagonists, where pupil dilation was mostly inhibited by tamsulosin among other alpha-1A-AR antagonists.[22]

According to Friedman,[23] vascular dysfunction of the iris is related to the blockade of alpha-1A-ARs in the blood vessel walls in patients taking tamsulosin. The vasculature of the iris serves as a skeletal structure for the iris, so any weakness promotes an intense dysfunction of the related muscle.[22],[23] The constrictive effect of tamsulosin on iris dilator contraction and vascular dysfunction can add to the IFIS effects seen in patients. Along these lines, patients who are taking tamsulosin could encounter a risk of IFIS during cataract medical procedures.[4],[24],[25] The chronic use of tamsulosin promotes atrophy of the macular plate and subsequent pupil expansion; this could explain the flaccid nature of this tissue discovered during cataract medical procedures.[26] Pärssinen et al. revealed that tamsulosin showed a delayed presence in the aqueous humor, suggesting a broadened activity on the ciliary body and iris.[26] This delayed activity of tamsulosin can cause lasting changes in the iris function by irreversibly inhibits alpha-1-ARs, causing permeant iris atrophy that may not revert upon discontinuation of the drug.[1],[4]

It has been suggested by some ophthalmologists to discontinue tamsulosin for 2 weeks before cataract surgery and to commence treatment immediately after surgery;[27] nevertheless, it has been reported that IFIS can still occur in patients who discontinued treatment even a year before the surgery.[4] Another study was not in favor of discontinuing tamsulosin before cataract surgery; considering the absence of conclusive evidence, they had recommended the use of iris hooks to avoid the need for altering current treatment.[28]

Tamsulosin induces intraoperative floppy iris syndrome

IFIS was first reported in 2002 in association with tamsulosin use, but the principal report of this disorder was not published until mid-2005.[4] Apart from alpha-AR antagonists, different other contributory risk factors were identified to be associated with IFIS, including decreased preoperative dilated pupil diameter,[22] increasing age,[29] male sex (attributed to the use of alpha-AR antagonists for BHP),[29],[30] certain medications such as antipsychotics and tranquilizers such as benzodiazepines,[29],[31] the use of angiotensin receptor inhibitors in females,[32] and the use of finasteride as an adjunct to alpha-1A-AR antagonists.[31] Notably, diabetes mellitus and hypertension were not found to be associated with IFIS.[33],[34]

The mechanism of tamsulosin induces IFIS has been reported by Prata et al.,[35] who showed a localized decline in the thickness of the iris dilator muscle in patients treated with tamsulosin because of irreversible muscle atrophy. This change increases the risk of adverse events, such as capsule rupture, vitreous misfortune, iris prolapse, iris stromal atrophy, and chamber bleeding,[14] and these complexities may cause a loss of corneal endothelial cells.[36],[37]

In a large cohort study conducted in Canada, 3550 patients (3.7%) had recent exposure to tamsulosin, of whom 284 (0.3%) had an adverse event. The study concluded that exposure to tamsulosin within 2 weeks of cataract surgery was significantly associated with serious postoperative eye adverse events.[38]

Lim et al.[39] detailed a lower rate of IFIS in Asian populations than in Western societies due to the darker iris color. Shah et al.[40] found an association between the billowing and flabby character of the iris and iris prolapse during phacoemulsification in patients taking tamsulosin 2 days before the day of the medical procedure.

The American Society of Cataract and Refractive Surgery issued a warning to all ophthalmologists regarding the relationship of tamsulosin with IFIS and expanded complexity rates and suggested the use of a nonselective alpha-blocker for treatment of BPH or commencing tamsulosin after phacoemulsification.[41]

Strategies to manage intraoperative adverse effects induced by tamsulosin

The authors suggested suspending tamsulosin treatment at 1–14 days before any cataract medical procedure.[4],[14] Others proposed that urologists should not change the recommended doses for alpha-blockers; however, they should suspend the administration of tamsulosin 7 days before any scheduled intraoperative medical procedure.[4],[42] Other strategies included:

Preoperative prophylaxis measures

Patients associated with a high risk to developing IFIS and those suffering BPH who are planning to undergo cataract surgery should be avoided the use of selective alpha-blockers and must inform their ophthalmologists about the intake of tamsulosin;[4] the disclosure of use before cataract surgery is highly important.[14],[42] As a precautionary measure, the urologist treating the patient can inform the ophthalmologist about tamsulosin treatment and other causative medications described earlier; if cataract surgery is under consideration, the ophthalmologists can then inform the patient to discontinue tamsulosin 7 days before an intraocular surgery.[42],[43]

Pharmacologic prophylactic strategies have demonstrated value in the prevention of IFIS; intracameral alpha-1-AR agonists effects, such as phenylephrine or epinephrine, can directly stimulate the iris dilator smooth muscle receptors, thereby diminishing the propensity toward iris prolapse and billowing.[44],[45],[46],[47] The use of preoperative topical atropine sulfate and intracameral nonpreserved epinephrine hydrochloride has been proven as an effective method to reduce the incidence of IFIS;[44],[45],[46],[47] the outcome is closely related to choice of surgical technique under the care of a senior ophthamologist.[48],[49]

A recent study to compare the prophylactic strategy in at-risk groups of IFIS receiving mydriatic treatments before phacoemulsification surgery showed a significant reduction of mild IFIS incidence, from 86.05% (n = 37/n = 43 patients) of atropine sulfate 1% treated group to 60.53% (n = 23/n = 38 patients) in adrenaline 1 mg/ml treated group. The analysis failed to show positive results in a reduction of severe forms, reconsidering ARA α1A withdrawal and a rational interruption of causative pharmacological treatment in some patients.[50]

Preoperative atropine drops (e.g., 1% three times/day for 1 to 2 days preoperatively) can augment cycloplegia. Due to the risk of intense urinary maintenance, systemic alpha-blockers should not be halted in general if atropine is utilized.[51]

Recently, the US Food and Drug Administration has approved a combination of phenylephrine 1% and ketorolac 0.3% intraocular use during cataract surgery to reduce the incidence of miosis, iris prolapse, and postoperative pain.[52]

Topical instillation of a lidocaine (2%) jelly, blended with cyclopentolate, phenylephrine, and ketorolac as a standard widening routine, can be utilized before the medical procedure.[44],[45],[46],[47],[50]

Intraoperative measures

Several methodologies have been proposed to deal with the iris in IFIS; these incorporate the utilization of highly viscous or visco-versatile ophthalmic viscosurgical devices and placement of mechanical widening gadgets.[4],[37]

All-around application of specific general surgical standards is recommended to maintain adequate pupil dilation at the time of routine cataract surgery for high-risk male patients on tamsulosin. It is critical for the optimal visualization, particularly if preoperative assessment concluded that IFIS is suspected to occur. The use of intracameral epinephrine was associated with lower incidence of IFIS. However, poorly dilated pupil after an intracameral epinephrine injection at the commencement of the surgery can be considered an early sign of potential incidence of IFIS.[4],[37],[53]

Strengths, limitations, and future research

The review has added more evidences from clinical trials and prospective observational studies to the evidence base regarding the ocular safety of tamsulosin and its interference with eye diseases, particularly IFIS.

The data presented here should be interpreted with caution, as this is not a systematic review. It is a simple descriptive literature review, where the design may not have identified all relevant studies. Several confounding morbidity factors and causative medicines were reported to be linked to IFIS. Most of the reviewed literature did not clearly define the adverse effects that were reported as an “ADR;” hence, the information provided is insufficient to assess the causality, severity, and preventability of ocular adverse reactions to tamsulosin. However, this review provided a considerable number of researches that linked IFIS to tamsulosin use that cannot be ignored.

Future studies on tamsulosin should use systematic review and meta-analysis designs to provide information about the incidence of ADRs that are relevant to alpha-blocker use and to develop intervention tools to improve alpha-blocker prescription and monitoring in different populations.


   Conclusion Top


This review provides a comprehensive summary of published research on tamsulosin use in different populations and its results have identified several articles that link tamsulosin and IFIS, an association that merits further investigation. However, the study design may not have identified all relevant studies, and the data do not provide sufficient information to assess the causality, severity, and preventability of ocular events related to tamsulosin. For this reason, inferences regarding the findings must be made prudently. Currently, there is no conclusive preventive strategy for the development of IFIS in high-risk patients. However, suspending of potential causative pharmacological treatment of IFIS before ocular surgery including tamsulosin, proper identification of at-risk patients, preoperative prophylaxis treatments, and surgical technique modifications clearly can mitigate the anticipated risk of IFIS induced by tamsulosin.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dunn CJ, Matheson A, Faulds DM. Tamsulosin: A review of its pharmacology and therapeutic efficacy in the management of lower urinary tract symptoms. Drugs Aging 2002;19:135-61.  Back to cited text no. 1
    
2.
Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984;132:474-9.  Back to cited text no. 2
    
3.
Hieble JP. International union of pharmacology. X. Recommendation for nomenclature of α_1-adrenoceptors: consensus update. Pharmacol Rev 1995;47:267-70.  Back to cited text no. 3
    
4.
Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005;31:664-73.  Back to cited text no. 4
    
5.
Li J, Tripathi RC, Tripathi BJ. Drug-induced ocular disorders. Drug Saf 2008;31:127-41.  Back to cited text no. 5
    
6.
Nakamura S, Taniguchi T, Suzuki F, Akagi Y, Muramatsu I. Evaluation of α1-adrenoceptors in the rabbit iris: Pharmacological characterization and expression of mRNA. Br J Pharmacol 1999;127:1367-74.  Back to cited text no. 6
    
7.
Aktas Z, Yuksel N, Ceylan G, Polat F, Hasanreisoglu M, Hasanreisoglu B. The effects of tamsulosin and alfuzosin on iris morphology: An ultrasound biomicroscopic comparison. Cutan Ocul Toxicol 2015;34:38-41.  Back to cited text no. 7
    
8.
Bosch J, Tilling K, Bohnen A, Bangma C, Donovan J. Establishing normal reference ranges for prostate volume change with age in the population-based Krimpen-study: Prediction of future prostate volume in individual men. Prostate 2007;67:1816-24.  Back to cited text no. 8
    
9.
Loeb S, Kettermann A, Carter HB, Ferrucci L, Metter EJ, Walsh PC. Prostate volume changes over time: Results from the Baltimore Longitudinal Study of Aging. J Urol 2009;182:1458-62.  Back to cited text no. 9
    
10.
Bosch JR, Bangma CH, Groeneveld FP, Bohnen AM. The long-term relationship between a real change in prostate volume and a significant change in lower urinary tract symptom severity in population-based men: The Krimpen study. Eur Urol 2008;53:819-27.  Back to cited text no. 10
    
11.
Roehrborn CG, Schwinn DA. α1-Adrenergic receptors and their inhibitors in lower urinary tract symptoms and benign prostatic hyperplasia. J Urol 2004;171:1029-35.  Back to cited text no. 11
    
12.
Yu Y, Koss MC. Functional characterization of α-adrenoceptors mediating pupillary dilation in rats. Eur J Pharmacol 2003;471:135-40.  Back to cited text no. 12
    
13.
Yu Y, Koss MC. Studies of α-adrenoceptor antagonists on sympathetic mydriasis in rabbits. J Ocul Pharmacol Ther 2003;19:255-63.  Back to cited text no. 13
    
14.
Pärssinen O. The use of tamsulosin and iris hypotony during cataract surgery. Acta Ophthalmol Scand 2005;83:624-6.  Back to cited text no. 14
    
15.
Goseki T, Ishikawa H, Ogasawara S, Mashimo K, Nemoto N, Taguchi Y, et al. Effects of tamsulosin and silodosin on isolated albino and pigmented rabbit iris dilators: Possible mechanism of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2012;38:1643-9.  Back to cited text no. 15
    
16.
Cantrell MA, Bream-Rouwenhorst HR, Steffensmeier A, Hemerson P, Rogers M, Stamper B. Intraoperative floppy iris syndrome associated with α1-adrenergic receptor antagonists. Ann Pharmacother 2008;42:558-63.  Back to cited text no. 16
    
17.
Sato S, Ohtake A, Matsushima H, Saitoh C, Usuda S, Miyata K. Pharmacological effect of tamsulosin in relation to dog plasma and tissue concentrations: Prostatic and urethral retention possibly contributes to uroselectivity of tamsulosin. J Pharmacol Exp Ther 2001;296:697-703.  Back to cited text no. 17
    
18.
Santaella RM, Destafeno JJ, Stinnett SS, Proia AD, Chang DF, Kim T. The effect of alpha1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth muscle anatomy. Ophthalmology 2010;117:1743-9.  Back to cited text no. 18
    
19.
Kenny B, Naylor A, Carter A, Read A, Greengrass P, Wyllie M. Effect of alpha, adrenoceptorantagonists on prostatic pressure and blood pressure in the anesthetized dog. Urology 1994;44:52-7.  Back to cited text no. 19
    
20.
Seo KK, Lee MY, Lim SW, Kim SC. Comparison of relaxation responses of cavernous and trigonal smooth muscles from rabbits by alpha1-adrenoceptor antagonists. J Korean Med Sci 1999;14:69-74.  Back to cited text no. 20
    
21.
Schwinn DA, Afshari NA. α1-adrenergic receptor antagonists and the iris: New mechanistic insights into floppy iris syndrome. Surv Ophthalmol 2006;51:501-12.  Back to cited text no. 21
    
22.
Casuccio A, Cillino G, Pavone C, Spitale E, Cillino S. Pharmacologic pupil dilation as a predictive test for the risk for intraoperative floppy-iris syndrome. J Cataract Refract Surg 2011;37:1447-54.  Back to cited text no. 22
    
23.
Friedman AH. Tamsulosin and the intraoperative floppy iris syndrome. JAMA 2009;301:2044-5.  Back to cited text no. 23
    
24.
Bidaguren A, Irigoyen C, Mendicute J, Gutiérrez E, Gibelalde A, Ubeda M. Floppy-iris syndrome associated with tamsulosin. A prospective case-control study. Arch Soc Esp Oftalmol 2007;82:349-54.  Back to cited text no. 24
    
25.
Leibovici D, Bar-Kana Y, Zadok D, Lindner A. Association between tamsulosin and intraoperative” floppy-iris” syndrome. Israel Med Assoc J 2009;11:45-9.  Back to cited text no. 25
    
26.
Pärssinen O, Leppänen E, Keski-Rahkonen P, Mauriala T, Dugué B, Lehtonen M. Influence of tamsulosin on the iris and its implications for cataract surgery. Invest Ophthalmol Vis Sci 2006;47:3766-71.  Back to cited text no. 26
    
27.
Brogden PR, Backhouse OC, Saldana M. Intraoperative floppy iris syndrome associated with tamsulosin. Can Fam Physician 2007;53:1148.  Back to cited text no. 27
    
28.
Chadha V, Borooah S, Tey A, Styles C, Singh J. Floppy iris behaviour during cataract surgery: associations and variations. Br J Ophthalmol 2007;91:40-2.  Back to cited text no. 28
    
29.
Kaczmarek IA, Prost ME, Wasyluk J. Clinical risk factors associated with intraoperative floppy iris syndrome: A prospective study. Int Ophthalmol 2019;39:541-9.  Back to cited text no. 29
    
30.
Issa SA, Hadid OH, Baylis O, Dayan M. Alpha antagonists and intraoperative floppy iris syndrome: A spectrum. Clin Ophthalmol (Auckland, NZ) 2008;2:735.  Back to cited text no. 30
    
31.
Chatziralli IP, Peponis V, Parikakis E, Maniatea A, Patsea E, Mitropoulos P, et al. Risk factors for intraoperative floppy iris syndrome: A prospective study. Eye (Lond) 2016;30:1039-44.  Back to cited text no. 31
    
32.
Tzamalis A, Malyugin B, Ziakas N, Tsinopoulos I. Angiotensin receptor inhibitors as main predisposing factor for intraoperative floppy iris syndrome in women. J Cataract Refract Surg 2019;45:696-7.  Back to cited text no. 32
    
33.
Altan-Yaycioglu R, Gedik S, Pelit A, Akova YA, Akman A. Clinical factors associated with floppy iris signs: A prospective study from two centers. Ophthalmic Surg Lasers Imaging Retina 2009;40:232-8.  Back to cited text no. 33
    
34.
Takmaz T, Can I. Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin. Eur J Ophthalmol 2007;17:909-13.  Back to cited text no. 34
    
35.
Prata TS, Palmiero PM, Angelilli A, Sbeity Z, De Moraes CG, Liebmann JM, et al. Iris morphologic changes related to α1-adrenergic receptor antagonists: Implications for intraoperative floppy iris syndrome. Ophthalmology 2009;116:877-81.  Back to cited text no. 35
    
36.
Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, et al. Clinical experience with intraoperative floppy-iris syndrome: Results of the 2008 ASCRS member survey. J Cataract Refract Surg 2008;34:1201-9.  Back to cited text no. 36
    
37.
Nguyen D, Sebastian R, Kyle G. Surgeon's experiences of the intraoperative floppy iris syndrome in the United Kingdom. Eye 2007;21:443-4.  Back to cited text no. 37
    
38.
Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson JM, Gruneir A, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009;301:1991-6.  Back to cited text no. 38
    
39.
Lim DH, Lee MG, Chung TY, Chung ES. Korean patients taking α1-adrenergic receptor antagonists show lower incidence of intraoperative floppy iris syndrome than western patients. Br J Ophthalmol 2014;98:479-83.  Back to cited text no. 39
    
40.
Shah N, Tendulkar M, Brown R. Should we anticipate intraoperative floppy iris syndrome (IFIS) even with very short history of tamsulosin? Eye 2009;23:740.  Back to cited text no. 40
    
41.
American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology Advise That Alpha-blockers Can Complicate Cataract Surgery; April 07, 2014. Available from: https://www.aao.org/newsroom/news-releases/detail/American-society-of-cataract-refractive-surgery-ac. [Last accessed on 2020 Dec 17].  Back to cited text no. 41
    
42.
Lawrentschuk N, Bylsma GW. Intraoperative 'floppy iris' syndrome and its relationship to tamsulosin: A urologist's guide. BJU Int 2006;97:2-4.  Back to cited text no. 42
    
43.
Abdel-Aziz S, Mamalis N. Intraoperative floppy iris syndrome. Curr Opin Ophthalmol 2009;20:37-41.  Back to cited text no. 43
    
44.
Shugar JK. Intracameral epinephrine for IFIS prophylaxis. Cataract Refract Surg Today 2006;32:72-4.  Back to cited text no. 44
    
45.
Masket S, Belani S. Combined preoperative topical atropine sulfate 1% and intracameral nonpreserved epinephrine hydrochloride 1: 2500 for management of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2007;33:580-2.  Back to cited text no. 45
    
46.
Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin: Staged approach. J Cataract Refract Surg 2006;32:1611-4.  Back to cited text no. 46
    
47.
Gurbaxani A, Packard R. Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin. Eye 2007;21:331.  Back to cited text no. 47
    
48.
Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. J Cataract Refract Surg 2010;36:898-905.  Back to cited text no. 48
    
49.
Nuzzi R, Arnoffi P, Tridico F. Best prophylactic strategy in groups at risk of intraoperative floppy iris syndrome development: Comparison between atropine instillation and adrenaline intracameral injection. Open Ophthalmol J 2018;12:34-40.  Back to cited text no. 49
    
50.
Silverstein SM, Rana VK, Stephens R, Segars L, Pankratz J, Rana S, et al. Effect of phenylephrine 1.0%-ketorolac 0.3% injection on tamsulosin-associated intraoperative floppy-iris syndrome. J Cataract Refract Surg 2018;44:1103-8.  Back to cited text no. 50
    
51.
Facio F, Kashiwabuschi R, Nishi Y, Leao R, McDonnell P, Burnett A. Benign prostatic hyperplasia: Clinical treatment can complicate cataract surgery. Int Braz J Urol 2010;36:563-70.  Back to cited text no. 51
    
52.
Enright JM, Karacal H, Tsai LM. Floppy iris syndrome and cataract surgery. Curr Opin Ophthalmol 2017;28:29-34.  Back to cited text no. 52
    
53.
Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114:957-64.  Back to cited text no. 53
    




 

Top
  
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Methods
   Results
   Conclusion
    References

 Article Access Statistics
    Viewed1233    
    Printed74    
    Emailed0    
    PDF Downloaded99    
    Comments [Add]    

Recommend this journal