Prostate Medication

Floppy Iris Syndrome: Know The Risks And Manage The Signs

Older people have a higher risk for certain conditions. Among men, both prostate problems and cataracts remain a common concern.

Studies show that the risk of benign prostatic hyperplasia is significantly increased in men over 40. The risk continued to increase as the man gets older. At the age of 90, about 60% of men are affected. 

Age also plays a role in the risk of conditions related to the eye. About 40% of people older than 75 will experience a cataract. Even in those aged between 43 and 54, the prevalence of cataracts is 2.9%. 

While these two conditions have no direct relation, there is still a risk that needs to be considered. Treatment with drugs for enlarged prostate may cause complications during cataract surgery. This may lead to a condition called floppy iris syndrome

We take a look at what floppy iris syndrome is. We consider symptoms and potential causes. We also look at how the condition is linked to BPH medication. The post will also discuss the current treatment options that are used for floppy iris syndrome. We also touch the subject on the potential preventative strategies that are currently available. 

What Is Floppy Iris Syndrome?

Floppy iris syndrome is not a condition on its own. Instead, it is considered a complication. The complication can develop as a result of surgery that removes cataracts.

The first case of floppy iris syndrome was reported in the year 20053. Since then, several reports have also been made. The condition is also referred to as intraoperative floppy iris syndrome. It affects the iris of the eye. In severe cases, the complication can cause problems with the patient’s vision. This is why the complication is sometimes referred to as a sight-threatening problem. 

Atrophy related to the dilator muscle in the iris is known to be the main component related to the condition. Flaccid iris billowing happens when a patient develops floppy iris syndrome. There are a few other things that can occur in the presence of the syndrome. 

Floppy iris syndrome is not a very common complication of cataract surgery. There is no completely accurate data on the epidemiology of the issue. Studies suggest that between 0.5% and 2% of patients who undergo cataract surgery will experience floppy iris syndrome2. 

In the majority of cases, floppy iris syndrome is linked to the use of certain medications. Age is also considered a major risk factor for the complication—age results in a higher risk of urinary tract problems and cataracts. In men, prostate problems generally cause urinary retention and similar symptoms. Treatment with medication for BPH may then lead to complications during cataract surgery. 

It does seem like the use of these medicines may result in a long-term risk for floppy iris syndrome. Some patients who develop the complication during cataract surgery did not take BPH drugs at present. Many of these, however, reported using such medicine in the past. 

Men do have a much higher chance of floppy iris syndrome. In fact, research has shown that men are about nine times more likely to develop floppy iris syndrome than women. 

It is still important to note that some BPH drugs are used in women with urinary symptoms. When this is the case, the female patient still experiences a higher risk for floppy iris syndrome.

IFIS patients may find it difficult to see clearly. There are cases where serious problems develop due to this complication. Iris tissue can be damaged in the process. The dilator muscle may fail to function properly. All of these causes a higher risk of more severe complications. 

What Are The Symptoms Of Floppy Iris Syndrome? 

Floppy iris syndrome is a complication that generally happens during cataract surgery. For this reason, the patient may not notice symptoms right away. Instead, the surgeons responsible for the cataract removal are the ones who may notice the complication. 

There are a few characteristics that have been associated with floppy iris syndrome. Surgeons should be able to recognize these characteristics. This ensures they can recognize floppy iris syndrome quickly. Appropriate action can then be taken to help reduce the risk of sight-threatening problems. 

The main effects that surgeons may notice when floppy iris syndrome develop during surgery include:

  • Flaccid iris billowing

  • Iris prolapse (happens through the incisions that were made during surgery)

  • Progressive miosis

What Causes Floppy Iris Syndrome? 

There are a few risk factors that have been associated with floppy iris syndrome. Patients should recognize all of the causes and risk factors. This helps them determine how likely they might be to develop the complication during a cataract-removal surgery. 

The use of tamsulosin is considered a significant cause behind floppy iris syndrome. Studies show up to 87% of patients with the syndrome took tamsulosin in the past. This is a drug commonly used to treat enlarged prostate in men

Other types of alpha-blocker drugs may also contribute to a higher risk of floppy iris syndrome. 

Thus, patients taking drugs for urinary symptoms need to mention this to a surgeon. It will ensure the surgeon can effectively assess the patient’s risk of floppy iris syndrome. 

It is also essential that patients understand stopping the use of these drugs does not lower their risk. Studies have found that the risk for floppy iris syndrome remains present even when a patient stops taking tamsulosin. 

There are also some predisposing risk factors that patients need to take note of. Some of these include:

  • Convex iris configuration

  • Low iris tonicity

  • A small pupil size

  • A shallow anterior chamber

Apart from these, patients with hypertension seem to be at a higher risk for the complication too. At the moment, it is not known if this risk may be caused by drugs for hypertension

Floppy Iris Syndrome And Tamsulosin

Tamsulosin is used to treat urinary symptoms. Doctors prescribe the drug for both men and women. It is a preferred treatment for men with an enlarged prostate. When a patient takes tamsulosin, it may help to improve urination. Urine flow may improve. Symptoms like urinary retention may also improve. 

The problem, however, is that the drug has a few risks. As noted, one risk is a higher chance of floppy iris syndrome during cataract surgery. 

There are different opinions regarding how the risk becomes present. Scientists believe that a-adrenergic receptors found on the muscle of the iris dilator may be involved. The use of an a-blocker drug seems to antagonize the a-adrenergic receptors. 

This effect causes two complications: 

  1. Impaired mydriasis

  2. Disuse atrophy

The patient experiences a risk of iris dysfunction. This can lead to problems when surgery is done on the eye. Cataract surgery holds the major risk when iris dysfunction is experienced. 

During the surgery, there may be a problem with initial mydriasis. This then leads to the billowing of the iris. Some patients also experience iris prolapse – which happens through the incision sites. 

While tamsulosin is the major risk factor behind this effect, other drugs can cause similar issues. Apart from tamsulosin, the following are drugs that patients should be wary of:

  • B-receptor blockers

  • Antipsychotic drugs

  • Finasteride

  • Certain antidepressants (Mianserin is an example)

  • Doxazosin, Indoramin, Prazosin, and other alpha-blockers

A few natural health supplements may hold similar risks. For example, men who take saw palmetto supplements for BPH may also be at risk or floppy iris syndrome. 

Prevention 

Due to the sight-threatening dangers of floppy iris syndrome, prevention is the preferred method. When the complication occurs, treatment may be difficult. There are times where the surgeon is not able to save the patient’s vision too. 

A few preventative strategies have been introduced. This helps to minimize a patient’s risk of developing floppy iris syndrome. 

Assessing The Risk For Cataracts

Prevention starts when the patient is provided a prescription for an alpha-blocker, such as tamsulosin. The doctor needs to ask the patient about their current symptoms when the patient presents with signs of benign prostatic hyperplasia. This should not only extend to the lower urinary tract. The doctor needs to take the risk of floppy iris syndrome into account. With this in mind, asking the patient about signs related to cataracts become essential. 

If the patient may have a risk for cataracts, then the use of tamsulosin is not advised. There are alternative drugs that the doctor may utilize as an initial treatment instead. 

The doctor may ask the patient to see an ophthalmologist if they suspect there is a risk for cataracts. An optometrist can conduct a thorough examination of the patient’s eyes. They will sometimes be able to provide details on whether or not there seems to be a risk. 

In fact, some literature recommends a complete ophthalmologic examination before providing a patient with any type of alpha-blocker. This is considered the safest routine. It is also a more effective preventative strategy. A few tests may be done on the patient, including pupil dilation. 

Prevention Prior To Surgery 

Some patients will still develop cataracts while using an alpha-blocker. This is a common issue that needs to be addressed. Appropriate preventative strategies need to be implemented in these cases too. 

The first step is to provide consideration for what happens prior to the cataract-removal surgery. 

If the patient is still taking the drug, they may be advised to discontinue its use. The problem, however, is that this may not significantly reduce the risk of floppy iris syndrome. For this reason, some surgeons will not consider stopping tamsulosin use prior to surgery, an effective preventative strategy. The same applies to other drugs, including alfuzosin.  

A complete analysis of the patient’s current medication is also needed. Remember that alpha-blockers are not the only drugs that contribute to floppy iris syndrome. The surgeon will be able to determine if other drugs may be putting the patient at an increased risk. The surgery may be postponed if the patient is taking multiple drugs associated with floppy iris syndrome. The surgeon may advise the patient to stop taking some drugs a while before the surgery. 

Sometimes routine cataract surgery is needed. Preventative strategies in these cataract patients should be taken prior to every surgery. Regardless of the surgical technique used, prevention at least helps to lower the risk of floppy iris syndrome. 

Prevention During Surgery

Sometimes, a surgeon can try and work around the risk of floppy iris syndrome. Once other preventative steps are taken, the surgeon can develop a plan to minimize the patient’s risk. Intracameral phenylephrine may be used as a small pupil cataract surgery.

A phacoemulsification surgery process may be used instead. This is a modern approach to cataract surgery. It uses an ultrasonic handpiece to perform the cataract extraction. 

The surgeon will also assist in minimizing the risk of other complications. This includes reducing the chances for a posterior capsular rupture

Treatment

Treatment for floppy iris syndrome is not a straightforward process. Even when treatment is initiated, the risk of losing sight quality remains. Some patients may also experience a loss of vision in the affected eye. 

The treatment will depend on a few factors. One important factor is for the surgeon to note the development of floppy iris syndrome. 

If the complication is noted, the surgeon should take action immediately. The surgical procedure may be halted for the time being. A thorough assessment of the floppy iris syndrome will be required. The surgeon will be able to see exactly how the iris dysfunction has affected the eye through such an examination. 

An appropriate treatment plan needs to be developed in this scenario. The treatment plan will be based on the surgeon’s findings. Surgeons may consider an iris retractor when cataract extraction is needed. 

A thorough examination will still be required if the complication is only identified after the surgery has been completed. The surgeon will need to examine the patient’s eye. They will then tell the patient the extent of the complication. Severe IFIS often require emergency treatment. The surgeon will have to act quickly, to save the patient’s vision in the affected eye. 

Conclusion

Floppy iris syndrome poses a serious threat to patients who need to undergo cataract surgery. The risk of the condition is highest among those taking drugs that are used to treat benign prostatic hyperplasia. Women also face a risk when these drugs are used to ease lower urinary tract symptoms. There are treatments available, but complications can still occur. Patients should understand their risk and discuss the possibility of floppy iris syndrome before surgery. 

Sources

  1. Asian Journal of Urology. (2017) Epidemiology of clinical benign prostatic hyperplasia. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717991/#:~:text=Clinical%20benign%20prostatic%20hyperplasia%20(BPH,60%25%20at%20age%2090%20years.
  2. 5-minute Clinical Consult. Floppy Iris Syndrome. [online] Available at: https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/816075/all/Floppy_Iris_Syndrome#7
  3. Review of Ophthalmology. (2018) IFIS: Know the Risks and Manage the Signs. [online] Available at: https://www.reviewofophthalmology.com/article/ifis-know-the-risks-and-manage-the-signs

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