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Moon, Choi, Ko, and Yoon: The Effect of Preoperative Homatropine for Intraoperative Floppy Iris Syndrome in Patients Taken Alpha Blockers
Original Article

J Korean Ophthalmol Soc 2019;60(1):32-39.

Published online: 25 September 2019

DOI: https://doi.org/10.3341/jkos.2019.60.1.32

The Effect of Preoperative Homatropine for Intraoperative Floppy Iris Syndrome in Patients Taken Alpha Blockers

Hyun Sik Moon, MD1, Jung Han Choi, MD1, Byung Yi Ko, MD, PhD2, Kyung-Chul Yoon, MD, PhD1,

1Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea

2Department of Ophthalmology, Konyang University College of Medicine, Daejeon, Korea

Address reprint requests to Kyung-Chul Yoon, MD, PhD Department of Ophthalmology, Chonnam National University Hospital, #42 Jebong-ro, Dong-gu, Gwangju 61469, Korea Tel: 82-62-220-6753, Fax: 82-62-227-1642 E-mail: kcyoon@jnu.ac.kr

Received 28 June 2018       Revised 29 August 2018       Accepted 28 December 2018

Copyright © 2019 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the effects of homatropine eye drops before cataract surgery to prevent intraoperative floppy iris syndrome (IFIS) in patients treated with alpha blockers.

Methods

The medical records of 98 eyes from 68 patients taking alpha blockers who underwent cataract surgery were retrospectively reviewed and divided into three groups: patients with preoperative instillation of homatropine (group 1), patients with preoperative instillation of atropine (group 2), and patients without preoperative eye drops (group 3) for three days. Age, sex, underlying disease, type of alpha blocker, preoperative and postoperative pupil size, parameters of phacoemulsification, surgical complication, and the degree of IFIS of patients were measured to compare among the three groups.

Results

No significant differences were found in age and underlying diseases. Significant differences were found in the pre-operative and postoperative pupil size, cumulative dissipated energy, and the incidence rate of iris prolapse through the incision sites among the three groups, but no significant difference was detected in other findings, or with regard to intraoperative or post-operative complications. In addition, the preoperative pupil size and preoperative instillation of 1% atropine were significant factors for decreasing the degree of IFIS.

Conclusions

Preoperative instillation of homatropine as well as atropine before cataract surgery minimized the degree of IFIS in patients taking alpha blockers. In addition, the pupil size recovered more rapidly after surgery in the homatropine group than in the atropine group.

Keywords: Alpha blocker, Cataract, Homatropine, Intraoperative floppy iris syndrome

References

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Figure 1.
Calculation of the intraoperative pupil size. The pupil size was calculated with the ratio of the horizontal length of the pupil (*) and the length between the limbus of cornea (†) compared with the preoperative horizontal diameter of the cornea. Intraoperative pupil size = (*, mm)/(†, mm) × pre-operative corneal diameter.
jkos-60-32f1.tif
Figure 2.
Distribution of the use of α-blockers among three group. Tamsulosin made up the largest number of α-blockers in all the groups.
jkos-60-32f2.tif
Table 1.
Comparison of characteristics among three groups taking α-blockers before cataract surgery
Variable Group 1 Group 2 Group 3 p-value*
1 vs. 2 1 vs. 3 2 vs. 3 All
Number of patients 20 26 22        
Number of eyes 28 32 38        
Age (years) 76.21 ± 7.11 76.94 ± 6.57 76.26 ± 4.30 0.89 0.80 0.48 0.50
Gender (male/female) 28/0 (100/0) 28/4 (87.5/12.5) 38/0 (100/0) 0.04† 1.00† 0.02† 0.01†
Nuclear density of cataract 3.25 ± 0.52 3.47 ± 0.67 3.37 ± 0.59 0.34 0.71 0.77 0.37
Systemic condition
 Hypertension (present) 12 (42.9) 22 (68.8) 26 (68.4) 0.10 0.09 1.00 0.06
 Diabetes mellitus (present) 10 (35.7) 10 (31.3) 14 (36.8) 0.93 0.99 0.88 0.88
 Dyslipidemia (present) 8 (28.6) 4 (12.5) 4 (10.5) 0.07 0.07 0.07 0.17
 Benign prostate hyperplasia (present) 28 (100) 28 (87.5) 38 (100) 0.04 1.00 0.02 0.01
Preoperative BCVA (logMAR) 0.44 ± 0.17 0.59 ± 0.50 0.59 ± 0.44 0.35 0.32 0.99 0.28
Preoperative maximum pupil diameter (mm) 6.78 ± 0.36 6.89 ± 0.92 6.14 ± 0.93 0.86 <0.01 <0.01 <0.01
Axial length (mm) 23.26 ± 0.22 23.30 ± 1.02 23.69 ± 0.89 0.98 0.09 0.12 0.06
Anterior chamber depth (mm) 3.18 ± 0.22 3.25 ± 0.46 3.04 ± 0.43 0.77 0.35 0.08 0.09

Values are presented as mean ± standard deviation or number (%) unless otherwise indicated. ‘Group 1’ means preoperative instillation of Homatropin 2%, ‘Group 2’ means preoperative instillation of Isopto atropine 1%, ‘Group 3’ means no preoperative instillation. BCVA = best corrected visual acuity; logMAR = logarithm of the minimum angle of resolution.

* One-way analysis of variance (ANOVA) test with Tukey's post-hoc test

† Chi-square test.

Table 2.
Comparison of characteristics among three groups taking α-blockers before cataract surgery (continued from Table 1)
Variable Group 1 Group 2 Group 3 p-value*
1 vs. 2 1 vs. 3 2 vs. 3 All
Intraoperative floppy iris syndrome (present/absent) 8/20 (28.6/71.4) 10/22 (31.3/68.7) 12/26 (31.6/68.4) 0.62 0.62 1.00 0.57
Grade of IFIS
 None (grade 0) 20 (71.4) 22 (68.7) 26 (68.4) 0.99† 0.02† 0.01† <0.01†
 Mild (grade 1) 8 (28.6) 9 (28.1) 0 (0)        
 Moderate (grade 2) 0 (0) 1 (3.1) 6 (15.8)        
 Severe (grade 3) 0 (0) 0 (0) 6 (15.8)        
Intraoperative phacodynamics
 Ultrasonic time (seconds) 43.38 ± 11.12 44.77 ± 20.38 61.12 ± 48.62 0.74 0.21 0.60 0.23
 CDE (mJ) 4.11 ± 0.97 4.14 ± 0.82 7.24 ± 6.28 0.99 0.02 0.01 <0.01
 BSS (used, mL) 65.89 ± 19.91 66.67 ± 21.46 77.53 ± 32.63 0.99 0.20 0.28 0.17
 Aspiration time (seconds) 202.57 ± 83.33 209.67 ± 56.75 236.60 ± 89.84 0.94 0.24 0.43 0.23
Intraoperative pupil diameter (mm)
 After hydrodissection 5.97 ± 0.46 6.00 ± 0.56 5.82 ± 0.95 0.98 0.67 0.52 0.51
 After phacoemulsification 6.20 ± 0.43 6.12 ± 0.78 5.65 ± 0.90 0.91 0.01 0.03 <0.01
 At conclusion of surgery 6.63 ± 0.51 6.63 ± 0.83 5.55 ± 0.95 1.00 <0.01 0.00 <0.01
Postoperative BCVA (logMAR) 0.01 ± 0.02 0.01 ± 0.04 0.01 ± 0.02 0.99 0.67 0.58 0.55
Postoperative maximum pupil diameter (1 day, mm) 5.01 ± 0.19 5.53 ± 0.76 4.46 ± 0.46 <0.01 <0.01 0.00 <0.01
Postoperative maximum pupil diameter (7 days, mm) 3.42 ± 0.34 3.44 ± 0.34 3.39 ± 0.38 0.99 0.94 0.90 0.90

Values are presented as mean ± standard deviation or number (%) unless otherwise indicated. ‘Group 1’ means preoperative instillation of Homatropin 2%, ‘Group 2’ means preoperative instillation of Isopto atropine 1%, ‘Group 3’ means no preoperative instillation. CDE = cumulative dissipated energy; BSS = balanced salt solution; BCVA = best corrected visual acuity; logMAR = logarithm of the minimum angle of resolution.

* One-way analysis of variance (ANOVA) test with Tukey's post-hoc test

† Chi-square test.

Table 3.
Intraoperative and postoperative complications among three groups taking α-blockers before cataract surgery
Complications Group 1 Group 2 Group 3
Patients 20 26 22
Eyes 28 32 38
Zonular dialysis 2 (2.6) 2 (6.3) 3 (7.9)
Posterior capsule rupture 0 (0) 1 (3.1) 2 (5.3)
Iris bleeding 1 (3.6) 2 (6.3) 2 (5.3)
Wound dehiscence 0 (0) 1 (3.1) 1 (2.6)

Values are presented as number (%) unless otherwise indicated. ‘Group 1’ means preoperative instillation of Homatropin 2%, ‘Group 2’ means preoperative instillation of Isopto atropine 1%, ‘Group 3’ means no preoperative instillation.

Table 4.
Comparison of intraoperative floppy iris syndrome manifestations among 3 group
Complications Group 1 Group 2 Group 3
Patients 20 26 22
Eyes 28 32 38
Progressive miosis 4 (14.3) 5 (15.6) 8 (21.1)
Iris billowing 6 (21.4) 10 (31.3) 12 (31.6)
Iris prolapse 2 (7.1) 1 (3.1) 10 (26.3)

Values are presented as number (%) unless otherwise indicated. ‘Group 1’ means preoperative instillation of Homatropin 2%, ‘Group 2’ means reoperative instillation of Isopto atropine 1%, ‘Group 3’ means no preoperative instillation.

Table 5.
Factors affecting the grade of intraoperative floppy iris syndrome in patients taking α-blocker before cataract surgery
Grade ≥ 2 vs. Grade ≤ 1 Univariate analysis
 Multivariate analysis
Risk ratio 95% CI p-value Risk ratio 95% CI p-value
Preoperative use of mydriatics
 Homatropine 2% 0.17 0.03–0.82 0.03 1.18 0.15–9.55 0.09
 Isopto atropine 1% 0.14 0.03–0.71 0.02 0.25 0.04–1.63 0.02
Preoperative maximum pupil diameter (mm) 0.18 0.08–0.39 <0.01 0.20 0.07–0.54 <0.01
Nuclear density of cataract 2.22 0.95–5.20 0.07 2.21 0.93–5.30 0.07
Cumulative dissipated energy 1.12 1.00–1.25 0.05 1.05 0.71–1.15 0.90

Variables with p > 0.20 in the univariate model were not shown in this table. Variables with p < 0.20 in the univariate model were entered in a multivariate model.

CI = confidence interval.

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