1. Quarterly Questions Sample Question

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Sample Question
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A patient presenting for cataract surgery is on tamulosin. Which of the following intraoperative maneuvers is most likely to decrease the effects of intraoperative floppy iris syndrome?
Enlarging the corneal incision
Placing incremental atropine
Creating iris sphincterotomies
Reducing the aspiration flow rate

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A patient presenting for cataract surgery is on tamulosin. Which of the following intraoperative maneuvers is most likely to decrease the effects of intraoperative floppy iris syndrome?
Enlarging the corneal incision
Placing incremental atropine
Creating iris sphincterotomies
Reducing the aspiration flow rate
Your answer is CORRECT.

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The key point addresses the subject matter knowledge necessary to answer the question correctly.
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Key Point:
Intraoperative maneuvers to help reduce the effects of floppy iris syndrome include reducing the aspiration flow rate and vacuum, use of mechanical iris expansion devices, placement of intracameral epinephrine, use of highly retentive viscoelastic, and avoiding an incision that is too large or too posterior (to reduce risk of iris prolapse).

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The critique (discussion) explains why the correct answer is the best choice, followed by reasons the other choices are not appropriate.
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Critique:
Intraoperative floppy iris syndrome is a characterized by the triad of 1) progressive pupil constriction during surgery, 2) billowing of the iris, and 3) tendency for iris prolapse into the phacoemulsification and side port incisions during surgery. This triad may or may not be associated with a poorly dilated pupil before surgery…

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Clickable references to further information about the content of the question are available.
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References:
Chang, DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114:
Flach, A. Intraoperative floppy iris syndrome: Pathophysiology, Prevention and Treatment. Trans Am Ophthalmol Soc 2009;107: