Sir,

Further to the paper entitled ‘Alpha antagonists and intraoperative floppy iris syndrome (IFIS) during Trabeculectomy’ by Au et al1 in May 2007 (the only reported case in the literature), we report two further cases—one anticipated, the other not.

Case 1: ‘the problem’

A 73-year-old Caucasian male with primary open angle glaucoma underwent augmented trabeculectomy surgery. Pilocarpine 4% was administered preoperatively. During the sclerostomy using a Khaw punch, the iris was noted to be atonic and immediately prolapsed through the ostium (see Figure 1). This was not anticipated.

Figure 1
figure 1

Prolapsing of the iris immediately after construction of the sclerostomy wound.

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With direct questioning on the operating table, the patient explained that he had been taking the α-1 antagonist, Tamsulosin®, but this had been stopped 3 months before. The diagnosis of IFIS was made. Several different methods failed to reposit the iris including: cutting a large peripheral iridectomy; stroking the cornea; sweeping the iris with a Rycroft cannula through the paracentesis; and using any intracameral injection (BSS, Miochol, or viscoelastic) exacerbated the prolapse. Ultimately, the scleral flap was sutured with one fixed 10/0 nylon suture and a second corneal paracentesis was made to sweep the iris back into the anterior chamber with the bimanual irrigation/aspiration probes. The remainder of the procedure was uncomplicated and the patient made excellent postoperative progress.

Case 2: ‘the solution’

A 62-year-old Caucasian male with chronic narrow angle glaucoma who was known preoperatively to be taking the αa-1 antagonist, Alfusozin® also underwent trabeculectomy surgery, but IFIS was anticipated. Before the sclerostomy, two limbal paracentesis incisions were made at the 3 and 9 o’clock positions using a 15° blade, through which iris hooks were used to draw the pupil into a fish mouth position (see Figures 2 and 3).

Figure 2
figure 2

Colour photograph illustrating the FISH Hook technique for preventing iris prolapse.

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Figure 3
figure 3

Illustrating the ‘fish mouthing’ of the iris using two iris hooks, preventing iris prolapse.

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The surgical peripheral iridectomy was easily performed on a taut superior iris. There was no spontaneous, flaccid iris prolapse. The hooks were removed after closure of the scleral flap and the two limbal side ports were hydrated. The iris returned to its preoperative position. The procedure was controlled and uncomplicated.

Comment

The first of our cases illustrates the difficulty in managing IFIS in filtration surgery. None of the suggested techniques reported in the literature1 worked in this case. An AC maintainer would exacerbate IFIS.

The second case describes the Floppy Iris Syndrome Hull Hooks (FISH Hooks) technique, which allows the surgeon to remain in complete control. Alternatively, a deep sclerectomy procedure, which avoids entering the anterior chamber, could be considered where IFIS is anticipated.