1. a.a. chen, md, ms m.c. wu, md j.p. kelly, phd a. bhandari, md university of washington department of ophthalmology seattle, wa the authors have no financial interest in this project incidence of floppy-iris syndrome during cataract extraction by resident physicians

2. INTRODUCTION intraoperative floppy-iris syndrome (IFIS) is a phenomenon consisting of:  billowing iris  iris prolapse  pupil constriction IFIS occurs among cataract surgery patients who have taken tamsulosin and/or other systemic alpha-1 antagonists (chang et al, jcrs 2008)

3. INTRODUCTION previously reported incidences of IFIS in patients taking tamsulosin: StudyNumber of eyesIFIS incidence Cheung et al, 20061730.0% Chadha et al, 20072157.0% Oshika et al, 20075843.1% Chang et al, 200716790.0% Blouin et al, 20072286.4%

4. PURPOSE the aims of this retrospective study were to determine:  (1) the reported overall incidence of IFIS in patients taking tamsulosin who undergo cataract extraction by a resident physician  (2) the reported incidence of IFIS in patients taking tamsulosin who receive prophylactic intracameral lidocaine/epinephrine (ILE) after paracentesis construction during cataract extraction by a resident physician

5. METHODS IRB approval was obtained power and sample size calculations were performed  assuming an IFIS incidence of 86.4% among those taking tamsulosin, a power of 0.80, and an alpha of 0.05, at least 55 charts would have to be reviewed in order to detect a one-sided 15% change in incidence among those who receive prophylactic ILE ophthalmology clinic notes and medications lists of 1163 consecutive patients who underwent cataract extraction by resident physicians at a single center between 1/2005 and 7/2008 were reviewed

6. METHODS 81 of 1163 cataract extractions were performed by resident physicians on patients taking tamsulosin operative notes for these cases were reviewed the following data were recorded for each case  preoperative dilated pupil diameter  use of prophylactic ILE after paracentesis construction  presence of billowing iris  presence of iris prolapse  presence of pupil constriction

7. RESULTS mean age of subjects was 76.5 years, SD 7.6 26 of 81 eyes (32.1%) received prophylactic ILE with IFIS defined as the occurrence of billowing iris, iris prolapse, and/or pupil constriction:  overall incidence of IFIS = 29.6%  incidence of IFIS among patients who did not receive ILE = 25.4%  OR 0.7, 95% CI = 0.36 to 1.3  incidence of IFIS among patients who received ILE = 38.5%  OR 1.2, 95% CI = 0.85 to 1.8 use of prophylactic ILE did not decrease the incidence of IFIS (P=0.174 by fisher’s exact test)

8. RESULTS preoperative dilated pupil diameter was reported in 75 of 81 operative notes mean preoperative dilated pupil diameter was 6.6 mm SD 1.3 small preoperative dilated pupils were defined as those with < 6.5 mm in diameter given the above definition, 29 of 75 (38.7%) of preoperative dilated pupils were reported as small

9. RESULTS among patients with small preoperative dilated pupils, the incidence of intraoperative pupil constriction was 37.9% among patients with large preoperative dilated pupils, the incidence of intraoperative pupil constriction was 13.0% the presence of a small preoperative dilated pupil was significantly associated with intraoperative pupil constriction (P=0.014 by fisher’s exact test)

10. CONCLUSION in this retrospective study of patients taking tamsulosin who have undergone cataract extraction by resident physicians:  the reported incidence of IFIS was 29.6%  the use of prophylactic intracameral lidocaine and epinephrine after paracentesis construction did not reduce the reported incidence of IFIS  the above incidence is lower than previously reported values  preoperative dilated pupil diameters < 6.5 mm were significantly associated with intraoperative pupil constriction

11. CONCLUSION this retrospective study’s limitations include possible confounding bias and recall bias further investigation is needed to clarify further the epidemiology of IFIS and determine possible methods for IFIS prophylaxis

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