Complicated Two-Phase Phacoemulsification Due To Intraoperative Floppy Iris Syndrome In A Hypermature Cataract Patient With Ankylosing Spondylitis Who Did Not Use Alfa1-Adrenergic Receptor Antagonist Medicine, Management: Case Report

To report a case of intraoperative Floppy iris syndrome (IFIS) in a patient who underwent complicated two-phase phacoemulsification with hypermature cataract who did not use alfa1-adrenergic receptor antagonist medicine before surgery

Department of Ophthalmology, “Lavanda” Eye Clinic, Yerevan, Republic of the Armenia

A 65-year male patient presented to ophthalmological clinic complaining with a gradual loss of vision․ Phacoemulsification with posterior chamber Intraocular lens (IOL) implantation in the left eye(LE)is indicated. Preoperative poor dilatation of the pupil was observed despite using a combination of phenylephrine 2,5%, cyclopentolate 1,0%, tropicamide 1,0% eye drops used for preoperative pupil dilatation of the left eye. Corneal paracenteses, anterior capsule staining, capsulorhexis (5.5 mm), hydrodissection and phacoemulsification (~60% of the lens) were performed. During phacoemulsification a progressive intraoperative pupil constriction, billowing of a flaccid iris stroma, iris prolapse to the surgical incisions, iridodialysis was observed and intraoperative occurrence of hyphema. No mydriatic injections and pupil enlargement devices were used. Phacoemulsification  was impossible to continue. After assessing the possibility of performing an anterior vitrectomy, the vitreoretinal surgeon carried out further surgery the following day․ A scleral tunnel was formed to the anterior chamber (5.0 mm). A capsular bag was used to implant the IOL after residual lens masses were removed without causing rupture to the posterior capsule. Pupiloplasty was performed․ 

One month after surgery

Visual Acuity (LE)=20/100 with pinhole 20/40
Intraocular pressure (LE)= 19 mm Hg.  
Cornea swollen, the pupil is wide, fixed, small iridodialysis, IOL is in capsular bag, eye fundus is normal. 

Intraoperative ISIF syndrome development is not only dependent on uroselective alfa1-adrenergic receptor antagonists as is known. All risk factors should be considered prior to surgery․ Preoperative pupil adequate dilatation is a crucial component, particularly for hypermature cataracts. Adequate fluid parameters during phacoemulsification, as well as intraoperative use of mechanical interventions and pharmacological therapies in such cases, are very important.