Eyeworld

I WHAT YOUR PATIENT IS TAKING AND ITS EFFECT ON THE EYE N FOCUS 56 | EYEWORLD | JANUARY/FEBRUARY 2020 Contact Lee: bryanlee@post.harvard.edu Myers: wmyers2020@gmail.com Safran: safran12@comcast.net said. "Others use intraoperative phenylephrine either compounded or in the commercial prod- uct Omidria." Dr. Safran said that he prefers the use of strong epi (1 ampule mixed with 4 cc balanced salt solution). Going into further detail, Dr. Myers said: "Prophylactic intraocular adrenergic agents, such as epinephrine buffered to neutral pH as in epi-Shugarcaine, will ameliorate the symp- toms. Those surgeons who routinely dilated patients with intracameral adrenergic agents and lidocaine did not see IFIS at all. Rarely, reduc- tion of pupil size that was gradual and con- trolled occurred but no iris billowing or rapid miosis. This is a case of having a cure for a disease before the disease existed. Atropine has been suggested as well, but it risks inducing uri- nary blockage. Topical agents are ineffective." Omidria was FDA approved in December 2017 as a phenylephrine 1% and ketorolac 0.3% intraocular solution for intraoperative miosis have been on it for a while and the effect is already in place on the iris, then stopping it will make no difference." Medical intervention So what can be done to reduce a floppy iris? "There are a few different approaches to try to reduce it medically," Dr. Lee said. "I usually use epinephrine in the bottle and inject phen- ylephrine into the anterior chamber to try to improve stability of the iris if I am concerned. You can use a dispersive viscoelastic to try to hold the iris in position early in the case, but eventually that OVD is going to have to be re- moved." Dr. Lee said he does not use the brand name phenylephrine and ketorolac (Omidria, Omeros), using instead intracameral phenyleph- rine at his surgery center. "I find that use of a concentration of epi- nephrine in the anterior chamber at the begin- ning of surgery can be very helpful to prevent IFIS in patients on alpha blockers," Dr. Safran continued from page 55 References 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tam- sulosin. J Cataract Refract Surg. 2005;31:664–673. 2. Santaella RM, et al. The effect of alpha1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth mus- cle anatomy. Ophthalmology. 2010;117:1743–1749. Relevant disclosures Lee: None Myers: Leiters Safran: None Same patient as in the prior two photos at 1 week after pars plana vitrectomy, exchange of damaged IOL for sutured PCIOL, and iris repair. Source: Steven Safran, MD continued on page 58

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