Floppy iris syndrome and cataract surgery

Curr Opin Ophthalmol 2017, 28:29–34

저번주에 예비군 훈련을 다녀온 후

환자들에게 제일 많이 듣는 소리가 ‘원장 아직도 예비군 가?’인데요…

어리게 봐주셔서 감사드립니다. 군의관으로 제대를 하나보니 남들보다 계급이 높은관계로

예비군을 오래동안 받게되네요…

아직은 나라에 필요한 인재인가봐요…

이제 공부좀 해볼까요

이번에 나온 논문으로

안과의사들이 백내장 수술할때 눈동자를 키운다는 이야기를 하는데요…

눈동자가 안커지는 분들이 있습니다. 바로 전립선약을 드신는 분인데요…

그래서 대부분 전립선약을 1-2주정도 끊고 수술을 합니다.

그런데 최근에는 연구되는 논문에서는 전립선약을 끊어도 수술시 효과가 없었다.

즉, 안끊으셔도 됩니다.  다만,, 못끊으니깐.,

소개된 방법

아트로핀 1%를 2일간 하루 3회 사용하면 효과가 좋습니다.

이래도 안커지면 수술시 에피네프린을 1:4000~1:10000으로 희석해서 눈에 넣어줍니다.

이래도 안커지면 벌리는 기구로 벌려줍니다.

수술방법에 약간 변화를 준다면 어렵지만은 않습니다.

연구하는 병원!! 앞서가는 대전 민들레안과에서…

Curr Opin Ophthalmol 2017, 28:29–34

Alpha-1 antagonists including tamsulosin (Flomax [Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT, USA] and Jalyn [GlaxoSmithKline, Philadelphia, PA, USA]), silodosin (Rapaflo [Allergan, Parsippany-Troy Hills, NJ, USA]), alfuzosin (Uroxatral, [Sanofi-Aventis, Paris, France]), doxazosin (Cardura [Pfizer Inc, New
York, NY, USA]), terazosin (Hytrin [Abbott Laboratories, Inc., North Chicago, IL, USA]), and prazosin (Minipress [Pfizer Inc, New York, NY, USA]) have the
strongest association with IFIS, although anumber of cases are associated with other classes of drugs and with hypertension. Notably, gender, race, and diabetes
are not independent risk factors for IFIS.

Tamsulosin is associated with the greatest risk for IFIS, presumably because of its high affinity and selectivity for the a1A-AR. Recent head-to-head studies comparing tamsulosin and alfuzosin (a nonselective a1-antagonist) indicated that IFIS was 30 times more frequent, and was more severe, in patients taking tamsulosin.  

Blouin MC, Blouin J, Perreault S, et al. Intraoperative floppy-iris syndrome associated with alpha1-adrenoreceptors: comparison of tamsulosin and alfuzosin. J Cataract Refract Surg 2007; 33:1227–1234.
Chang DF, Campbell JR, Colin J, et al. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin. Ophthalmology 2014; 121:829–834.

Nonselective a1-antagonists are associated with a lower, but not negligible, risk of IFIS. Alfuzosin, terazosin, and doxazosin are all independent risk factors for IFIS, with odds ratios of 9.7, 5.5, and 6.4, respectively

Typical and atypical antipsychotics with a1-antagonist activity, including chlorpromazine(Thorazine), zuclopenthixol (Clopixol), and quetiapine(Seroquel), have also been associated with IFIS.

Several neuromodulators including benzodiazepines, duloxetine (Cymbalta, a serotonin-norepinephrine reuptake inhibitor [SNRI]) and donepezil (Aricept, an acetocholinesterase inhibitor)have been implicated in IFIS.
While cholinergics are expected to oppose mydriasis, the mechanistic link between duloxetine and benzodiazepines and IFIS is less clear.

A small, but growing, body of evidence indicates that finasteride (Propecia, a 5a-reductase inhibitor) may mildly increase the risk of IFIS. Iris billowing
was seen in rabbits treated with finasteride . Finasteride was the likely causative agent in three case reports of IFIS, and was independently associated
with IFIS in a recent large-scale retrospective study.

Hypertension has been demonstrated as an independent risk factor for IFIS in three of four largescale studies . It is unclear whether this risk is associated with antihypertensive medications, or is a direct effect of hypertension on iris physiology (such as by altering the number or affinity of adrenoreceptorsin the iris vasculature). Notably, the  beta blockers labetalol and carvedilol do have a1- antagonist activity, and labetalol was implicated in a case report of IFIS . Further large-scale efforts are needed to rigorously explore a potential link between these commonly prescribed antihypertensives and IFIS

Women are prescribed tamsulosin for chronic urinary retention, and tamsulosin is also used off-label to facilitate passage of urinary stones in both men and women.

PREOPERATIVE MANAGEMENT OF INTRAOPERATIVE FLOPPY IRIS SYNDROME

Atropine, a muscarinic agonist, has been used preoperatively to assist pupillary dilation. A common regimen is 1% atropine applied thrice daily for
2 days prior to surgery. When used alone, atropine is often ineffective for more severe cases of IFIS, but it may be helpful when used in conjunction with
other treatments.

INTRAOPERATIVE MANAGEMENT OF INTRAOPERATIVE FLOPPY IRIS SYNDROME

Chang and Campbell first noted that traditional interventions for small pupil (i.e., mechanical pupil stretching and partial sphincterotomy) were not helpful in IFIS, due to the elastic nature of the iris . Instead, in addition to surgical technique modifications noted below, the cornerstones of IFIS management are
intracameral a-adrenergic agonists, ophthalmic viscosurgical devices (OVDs), iris retractors, and pupil expanders.

Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673.

Using low-flow phacoemulsification settings, maintaining the irrigation source anterior to the iris, and performing gentle hydrodissection minimize iris movement. Discontinuation of fluid inflow prior to withdrawing instruments prevents fluid and iris egress. Bimanual microincision techniques may also be employed. However, in severe IFIS, prolapse may still occur and additional interventions may be needed.

Preservative- and bisulfite-free epinephrine is preferred, but there has been a shortage of bisulfite- free epinephrine in the United States [46]. Epinephrine
1 : 1000 containing bisulfite should be diluted to 1 : 4000 in BSS to prevent corneal epithelial damage.

Traditionally, 1% lidocaine is instilled with the epinephrine and phenylephrine. However, a recent study comparing the first and second eyes of 18 patients on tamsulosin suggests that epinephrine alone may be superior to epinephrine with lidocaine.

Iris retractors and pupil expanders are easiest to employ prior to performing the capsulorrhexis. A diamond configuration of iris retractors is recommended,
with one of the retractors located directly beneath the primary incision.

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