1. RESULTS DISCUSSION RECOMMENDATIONS
Let’s talk about intraoperative floppy-iris syndrome: an opportunity to reduce the risk
S Khan 1 H Hasan 1 S Dhanireddy 1 
1 Great Western Hospital, Swindon, UK.
Despite 40% of GPs having heard of IFIS, none enquired about imminent cataract surgery and 75% were unaware of the association between IFIS and adrenergic blockade. Therefore, increasing awareness and understanding at the community level has a role in preventing IFIS and would be viable based on out pilot survey showing GPs as highly receptive to adapting their practises in clinic.
Singh DV, Mete UK, Mandal AK, and Singh SK. A comparative randomized prospective study to evaluate efficacy and safety of combination of tamsulosin and tadalafil vs. tamsulosin or tadalafil alone in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. J Sex Med 2014;11:187–196.
Monotherapy with Tadalafil or Tamsulosin Similarly Improved Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia in an International, Randomised, Parallel, Placebo-Controlled Clinical TrialMatthias OelkeCorrespondence information about the author Matthias Oelke the author Matthias Oelke, François Giuliano, Vincenzo Mirone, Lei Xu, David Cox, Lars Viktrup
Intraoperative floppy-iris syndrome (IFIS) is becoming a routine encounter for the twenty-first century ophthalmologist. Classically the features of IFIS are a billowing iris, progressive miosis and iris prolapse.
It is associated with higher complication rates, poorer visual outcomes and reduced surgical opportunities for ophthalmic trainees. A UK-based prospective case review conducted between found 13.5% of individuals on systemic alpha-1A receptor blockade encountered a complication during cataract surgery compared to 3.3% in the control group. The aetiology involves systemic alpha-1 receptor antagonism leading to permanent remodeling of the iris sphincter muscle.
To educate general practitioners (GPs) on IFIS and canvas opinion on delayed initiation of systemic alpha-adrenergic blockers such as Tamsulosin for treating benign prostatic hyperplasia, should cataract surgery be imminent.
INTRODUCTION
AIMS
Fully qualified GPs were anonymously surveyed on their current prescription practises for the treatment of benign prostatic hyperplasia and a short educational excerpt on IFIS and associated complications was included for informative purposes.
METHODS
RESULTS
Tamsulosin was prescribed as first-line treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia by 100% of GPs.
Over 60 % of GPs were not aware of IFIS.
40 % of GPs has less than 1 week of ophthalmology experience; combined 71% had between 0 – 4 weeks’ of ophthalmology experience.
Prior to initiating alpha-receptor blockade none as part of normal practise enquired about upcoming cataract surgery.
25 % are aware of an ophthalmic condition associated with alpha-adrenergic blockade.
Which of the following side-effects do you counsel your patients about who are being initiated on alpha-adrenergic receptor blockade therapy for BPH?
100%
81%
24%
14%
10 %
10 %
5 %
0 %
10 %
38%
100 %
40 %
14 %
DISCUSSION
If floppy iris syndrome is something you have not been aware of before, following reading the educational excerpt, do you think you will change your clinical consultation to include a short ophthalmic assessment or take a history related to possible future cataract surgery prior to initiating alpha-adrenergic blockers?
60 %
We have learnt that GPs are highly receptive to adapting their practices to reduce the incidence of IFIS following delivery of our educational questionnaire and access to an online ‘Question and Answer’ forum.
The key question which has arisen from our survey is:
How can we reduce the incidence of IFIS?
1. Delayed prescription of alpha-adrenergic receptor blockers until after surgery.
This targets the irreversible structural changes caused by these drugs on the iris radial muscles which are usually apparent after 6 months of treatment.
2. Use of alternative first-line agents e.g. Tadalafil (Cialis) a cGMP phosphodiesterase -5 inhibitor. This drug has a comparable side effect profile to tamsulosin without IFIS risk and equally highly effective for BPH treatment with the additional benefit of improved quality of life scores. In 2013 it received EU marketing authorisation for the treatment of signs and symptoms of BPH, however its annual cost is £ compared to tamsulosin £65.33 annually .
33%
10 %
5 %
86% NO
95 %
75 %
25 %
YES
RECOMMENDATIONS
Community recommendation:
Consider Tadalafil for treatment of BPH in those newly diagnosed patients who are phakic.
Encourage questioning about forth-coming cataract surgery and if imminent, delay starting alpha-adrenergic blockade or consider Tadalafil as a bridging option.
Further interaction with GPs regarding the introduction of the licensed Tadalafil as possible first-line agent and implications of cost, delayed initiation of Tamsulosin.
Continue to raise awareness of IFIS in the community by expanding the questionnaire to cover multiple CCGs.
Hospital based recommendations:
Educate ophthalmic trainees from an early stage on how to manage patients likely to develop IFIS and to pre-empt miosis with a range of devices e.g. iris hooks, intracameral phenylephrine, OVDs.
Ensure previous and current medications are reviewed for alpha- adrenoceptor blockade.
Cost vs complications Cartesian analysis.
No treatment
Surgery and Tamsulosin
What is the real cost to the NHS of complications?