PHLOROGLUCINOL INDUCED INTRAOPERATIVE FLOPPY IRIS SYNDROME

Since the description of the “Intraoperative floppy-iris syndrome” (IFIS) by Chang and Campbell in 2005, the understanding of the role of adrenergic receptors in iris biology has gained widespread interest. The iris has only recently been recognized as a tissue with an immensely complex biology that isn’t limited to the simple balance between sympathetic and parasympathetic nerve activity.

The IFIS has been reported alongside the use of alpha-antagonists, particularly tamsulosin and doxazosin. Recent reports suggest that other pharmaceutical agents may induce this IFIS.To our knowledge, no case of phloroglucinol induced IFIS was ever reported.

The purpose of this presentation is to notify cataract and refractive surgeons about the possible association of phloroglucinol intake and the intraoperative floppy iris syndrome. We also suggest some ways to anticipate and prevent such complications during our surgeries.

We report the case of a 61 y.o. male treated with Phloroglucinol for a long-standing post-operative abdominal pain, no urologic or other medication history is reported. The patient is addressed to our center for cataract surgery after a long evolving vision blurring.

The preoperative corrected distance visual acuity was around 20/70 in both eyes. Slit lamp examination showed a bilateral moderate corticonuclear cataract. Dilated pupil diameter was poor at 3.5mm. Fundus examination was normal.

The patient is scheduled for cataract surgery under topical and intracameral anesthesia. Iris retractors were brought in case of insufficient pupil size.

We make a paracentesis with a longer tunnel than usual regarding our suspicions of an abnormal iris tonicity. The iris prolapses completely from the incision, and seems indeed flaccid, confirming we are facing a severe intraoperative floppy iris syndrome case. The pupil size becomes very restricted.

The management of IFIS cases any step can become very tricky and the surgery requires a deep understanding of the phaco fundamentals and anterior chamber parameters. Any manipulation of the iris should be avoided and in the bag nucleus division techniques prefered. The eventuality of a suture should be discussed due the risk of a post-operative iris prolapse, in our case we found that a hydrosuture was watertight enough.

Recent studies has shown that phloroglucinol can penetrate the blood-brain barrier. It is an antispasmodic agent that leads to muscle relaxation by inhibiting voltage dependent calcium channels. Many antispasmodic agents can have an anticholinergic activity as a side effect too. Data regarding the efficacy and safety of phloroglucinol is very limited despite its widespread use.

- Phacoemulsification era has brought a wealth of scientific knowledge regarding iris receptor affinities and how medications can disrupt iris physiology

- Phloroglucinol or any prior medication intake should raise IFIS probability and suspicions

- Minimal iris manipulation is the rule to manage such cases