Surgeon's experiences of the intraoperative floppy iris syndrome in the United Kingdom

Surgeon's experiences of the intraoperative floppy iris syndrome in the United Kingdom
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  Sir, Surgeon’s experiences of the intraoperative floppy irissyndrome in the United KingdomIntroduction Intraoperative floppy iris syndrome (IFIS) in associationwith tamsulosin occurs during cataract surgery and isassociated with an increased complication rate. 1 Weconducted a survey of UK consultant ophthalmologiststo increase their awareness and gather information on thegeneral epidemiology and current management of IFIS.Fifty-three per cent of consultants had encountered thesyndrome either retrospectively or prospectively in maleand female patients on tamsulosin as well as other a -receptor antagonists (Table 1). Although 68% of consultants had patients discontinue tamsulosinpreoperatively, they reported no consistent benefit fromthis step. Sixty-one per cent chose iris hooks, and 72% of that group had found them effective in managing floppyirides intraoperatively. Twenty-seven per cent usedHealon 5 (Advanced Medical Optics) and low aspirationsettings, and 85% found the technique effective. Theuse of intracameral phenylephrine has been recentlydescribed in the peer-reviewed literature, 2 and only2% had used this method. Twelve per cent, however,reported that they would consider this measure forfuture cases of IFIS. Other options for managementincluded bimanual microincisional phacoemulsification,mechanical pupil rings, and the preoperativeadministration of atropine (Figure 1). Comment Our survey revealed IFIS can occur with all  a - 1 ARantagonists with an isolated case of IFIS in a patient onalfuzosin recently described. 3 The persistence of IFIS,despite discontinuing tamsulosin, suggests that it mayoccur independent of dosage or duration of treatment;however, it is presently not possible to conclude thatdiscontinuation is of no benefit. The majority of UKconsultants now directly ask patients regarding theirhistory of prostate medication, and some eye units haveincorporated this question specifically into theirpreoperative assessment process. As a result, thepotential for IFIS may be included as appropriate in theinformed consent. These patients are educated abouttheir increased likelihood of a technically difficultoperation and possible complications, includingprolonged postoperative corneal oedema, uveitis, glare,and dysphotopsia. Posterior capsule rupture occurred in7% of patients in our survey compared to a previousreport of 12.5%. 1 Table 1  IFIS patient drug history Drug Male Female Tamsulosin 355 8Alfuzosin 3Doxazosin 5 1Prazosin 2Terazosin 1Unknown drug Hx 211 18 Total male 579, female 27. 010203040506070Have usedWould considerIris HooksHealon 5 & low aspirationIntracameral PhenylephrineBimanual PhacoPupil RingPre-op Atropine 1%  % 61432742212513122 Figure 1  Surgical techniques that surgeons had or indicated that they would use to manage IFIS. Correspondence 443 Eye  A degree of reporting bias may exist in the sample thatresponded to our questionnaire and this may haveskewed the results. We believe this to be limited as ourpurpose was to explore individual experiences anddetermine if there was a general consensus amongthe array of measures that exists. 2,4–6 Although theprevalence, incidence, and associated risk factors of IFISare not yet known, it is important for ophthalmologists toanticipate the potential operating difficulties with IFIS and be aware of the wide range of management optionsavailable. Acknowledgements We thank all the ophthalmologists who returned thequestionnaire contributing to this survey and Rita Taylorfor her administrative help. References 1 Chang DF, Campbell JR. Intraoperative floppy iris syndromeassociated with Tamsulosin.  J Cataract Refract Sur  2005;  31 :664–673.2 Gurbaxani A, Packard R. Intracameral phenylephrine toprevent floppy iris syndrome during cataract surgery inpatients on Tamsulosin.  Eye  [November 11; E-pub ahead of print].3 Settas G, Fitt AW. Intraoperative floppy iris syndrome in apatient taking alfuzosin for benign prostatic hypertrophy.  Eye 2006 [February 24; E-pub ahead of print].4 Arshinoff SA, Wong E. Understanding, retaining andremoving dispersive and pseudodispersive ophthalmicviscosurgical devices.  J Cataract Refract Surg  2003;  29 :2318–2323.5 Oetting TA, Omphroy LC. Modified technique using flexibleiris retractors in clear corneal surgery.  J Cataract Refract Surg 2002;  28 : 596–598.6 Chan DG, Francis IC. Intraoperative management of irisprolapse using iris hooks.  J Cataract Refract Surg  2005;  31 :1694–1696. DQ Nguyen 1 , 2 , RT Sebastian 1 and G Kyle 1 1 Department of Ophthalmology, University AintreeNHS Trust, Bath, UK 2 Department of Ophthalmology, Royal UnitedHospital Bath, Combe Park, Bath BA1 3NG, UKCorrespondence: DQ Nguyen,Department of Ophthalmology,Royal United Hospital Bath,Combe Park,Bath BA1 3NG, UKTel:  þ 44 07971 929 856;Fax:  þ 44 0117 928 4721.E-mail: danqbnguyen@hotmail.comFunding: Astellas Ltd met the administrative costsof the survey. Eye  (2007)  21,  443–444. doi:10.1038/sj.eye.6702616;published online 20 October 2006Sir, Ptosis caused by orbicularis myokymia and treatedwith botulinum toxin: a case report Myokymia is a manifestation of peripheral nerve diseaseand classified as excess motor unit activity.Electrophysiologically, it consists of rhythymic orsemirhythymic bursts of grouped motor unit potentialsoccurring at a uniform rate of 2–60Hz, usually with2–10U within a burst. 1,2 We present a 23-year-old ladywho presented with left upper eyelid ptosis caused byorbicularis myokymia and treated with botulinum toxininjection. Case report  A 23-year-old systemically healthy lady presented withcomplaints of ptosis of the left upper eyelid, presentpersistently since 3 months.On examination, the best-corrected visual acuity was6/6, in both eyes. The left upper eyelid was 1mm lowerin position and the lower eyelid was 1mm raised,compared to the right eye. There was increased tonenoted in the lower eyelid pretarsal orbicularis (Figure 1a).The left upper eyelid showed the presence of constant,rhythmic, fibrillations. The ptosis was constant, onevaluation on three different days, for an hour each. Post-closure, the upper eyelid was also slower to open. Thelevator action was 15mm and the lid crease height was8mm, in both eyes. Remaining ocular examination wasunremarkable.Magnetic resonance imaging of the central nervoussystem was unremarkable. Special attention was paid tothe VII nerve complex and the cerebropontine angle torule out a dolichoectatic basilar vessel compression onthe VII nerve, as a possible cause. Electro-myography of the left orbicularis muscle was performed anddemonstrated over-activity (Figure 1b).The patient was diagnosed to not only have uppereyelid ptosis, but also reversed ptosis of the lower eyelid;due to increased tone of the orbicularis oculi.A total of 5U of botulinum toxin – A injection (Botox,Allergan, Irvine, CA) was given in two locations,intradermally and pretarsally, to the left upper eyelid andto the lower lid, respectively. The orbicularis activity Correspondence 444 Eye
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